Dhs HR Health in Asia and The Pacific 13 Chapter 8 Priority Noncommunicable Diseases and Disorders

8
Priority noncommunicable
diseases and conditions
This chapter reviews the situation of priority noncommunicable diseases (NCDs) in the Asia Pacific
Region, with subchapters covering the well-known “lifestyle” diseases, tobacco control, injuries and
violence, mental and neurological illness and substance abuse, and thalassaemia.
Due to rapid epidemiological and demographic transitions, chronic NCDs have become a leading
cause of death, morbidity and disability in the Region. Cardiovascular diseases, cancer, chronic lung
diseases and diabetes have emerged as major public health problems, and mental health and associated
disorders affect a great number of people, especially in the more industrialized countries. Certain
genetic diseases are being increasingly recognized and the incidence of accidents and other injuries
are growing.
High levels of major risk factors for NCDs in much of the Region suggest that resulting health
problems will continue to rise and affect progressively younger age groups, creating a significant impact
on the workforce and on overall development. Families and communities of sufferers are also affected
through direct and indirect economic loss. The increasing incidence of NCDs among poor and vulnerable
groups is widening health inequities within and between countries.
The causes of NCDs are known and are mostly modifiable. Unhealthy diet, physical inactivity and
tobacco consumption are risk factors common to several major NCDs. Although many socioeconomic
and behavioural factors lie outside the domain of the health sector, health systems should assume
responsibility for prevention, care and treatment of most NCDs and prepare for the additional burden
and resource needs this will bring.
Effective collaboration between health and other sectors could prevent up to 80% of all cases of
heart disease, stroke and diabetes, and 40% of cancers.1 Accidents and violence are largely civil and
regulatory issues. Mental illness is a direct family and community concern. More intersectoral involvement
down to the community level is needed to manage many of these problems on a large scale. Coordinated
international efforts have so far focused on tobacco control and the implementation of the first global
Chapter 8
public health treaty, the WHO Framework Convention on Tobacco Control.
8.1 Lifestyle diseases

Cardiovascular diseases
Cardiovascular disease (CVD) is a range of conditions dominated by coronary heart disease, also
referred to as ischaemic heart disease. In a process known as atherosclerosis, a slow accumulation of
fatty plaques eventually narrow and block the heart’s coronary arteries. This starves the heart muscle
of blood and causes crippling chest pain or a heart attack. By blocking critical blood vessels of the
brain, atherosclerosis is also responsible for the majority of strokes (cerebrovascular disease). The
global upsurge in CVD is due to changing lifestyles that accelerate the risk of atherosclerosis, such as
the growing prevalence of obesity, smoking and high blood pressure, as well as dietary changes and
diminished physical activity, all discussed later in this chapter. Rheumatic heart disease falls under
CVD but is caused by infection and is, therefore, discussed separately on page 293.
Projected to be the leading killer in all countries by 2020,2 CVD is responsible for nearly 17 million
deaths a year, a staggering one third of global mortality and over 10% of the entire global burden of
disease.3 By comparison, HIV/AIDS claims 3 million lives annually.4 Often incorrectly seen as a disease
of wealthy nations, most deaths from CVD occur in developing countries. As a rising wave of CVD
engulfs the Asia Pacific Region, throwing enormous strain on health systems and felling ever growing
numbers of people in their most productive years, it poses a grave threat to economic development.
By adding to the burden of poor families, who lack the resources to cope when a heart attack or stroke
strikes a family member, CVD also creates health inequity.
There were over six million deaths due to CVD in the Region in 2002, with mortality equally
divided between ischaemic heart disease and stroke. The absolute burden is similar for males and
females. Overall death rates for ischaemic heart disease are higher among men than women, but
these differences are not so pronounced for stroke.5 In some Pacific island countries, Mongolia and
Thailand, death rates from stroke are higher among women. Bhutan and India have one of the highest
age-standardized rates for ischaemic heart disease for both males and females, while Fiji has the
highest rate for males at 304/100 000, and the Maldives the highest rate for females at 218/100 000.
Sri Lanka has the highest rate for stroke for males (256/100 000) followed by Vanuatu, Australia and
Brunei Darussalam. Mongolia has the highest rate of stroke for females (189/100 000) followed by
Tuvalu, Nauru and the Marshall Islands.
Figures 8.1 and 8.2 show mortality estimates for the Asia Pacific Region for females and males for
ischaemic heart disease, and Figures 8.3 and 8.4 show mortality estimates for females and males for
stroke.
Derived from the WHO Global InfoBase,6 Table 8.1 shows the burden of CVD for the Asia Pacific
Region in terms of disability-adjusted life years (DALYs) lost. It can be seen that the Region contributed
to over half the world burden attributable to CVD in 2005, with just over 78 million DALYs lost.
Ischaemic heart disease and cerebrovascular disease contribute the major burden of DALYs lost both
globally and in the Region.
288 Health in Asia and the Pacific

Fig. 8.1 Age-standardized death rates (per 100 000 population) for ischaemic heart disease
among females in selected countries and areas in the Asia Pacific Region, 2005
Maldives 218
Bhutan 202
India 198
Lao PDR 194
Bangladesh 194
Nepal 178
Papua New Guinea 172
Myanmar 168
Timor-Leste 167
Indonesia 144
DPR Korea 131
Cambodia 118
Viet Nam 107
Philippines 97
Tuvalu 95
Nauru 90
Marshall Islands 88
Malaysia 83
Sri Lanka 78
Singapore 76
Fiji 76
Samoa 73
Micronesia 70
Vanuatu 69
New Zealand 69
Tonga 67
Solomon Islands 67
Palau 66
China 63
Mongolia 58
Thailand 56
Australia 56
Niue 53
Cook Islands 52
Brunei Darussalam 43
Republic of Korea 28
Japan 21
Kiribati 6
0 50 100 150 200 250 300 350

Age-standardized death rate per 100 000 population
Source: WHO global infobase: data for saving lives. Geneva, World Health Organization. See: http://
www.who.int/infobase/compare.aspx
Priority noncommunicable diseases and conditions 289

Fig. 8.2 Age-standardized death rate (per 100 000 population) for ischaemic heart disease
among males in selected countries and areas in the Asia Pacific Region, 2005
Chapter 8
Fiji 304
Bhutan 277
India 268
Timor-Leste 247
Malaysia 246
Bangladesh 245
Myanmar 238
Maldives 233
Palau 232
Nepal 230
Indonesia 194
Mongolia 193
Viet Nam 186
Lao PDR 176
DPR Korea 176
Japan 175
Singapore 172
Tonga 170
Samoa 158
Micronesia 154
Niue 151
Solomon Islands 150
Marshall Islands 148
Vanuatu 141
New Zealand 137
Tuvalu 130
Philippines 127
Nauru 123
Cook Islands 123
Cambodia 79
Thailand 74
Australia 74
China 49
Kiribati 47
Sri Lanka 21
0 50 100 150 200 250 300 350


Fig. 8.3 Age-standardized death rates (per 100 000 population) for stroke among
females in selected countries and areas in the Asia Pacific Region, 2005
Mongolia 189
Tuvalu 181
Nauru 161
Lao PDR 146
Fiji 140
China 140
Samoa 131
Maldives 130
Micronesia 128
Vanuatu 125
Solomon Islands 123
Bhutan 121
Tonga 121
India 117
Palau 117
Bangladesh 114
Viet Nam 108
Myanmar 107
Cambodia 105
Nepal 103
Indonesia 99
Timor-Leste 98
Niue 98
Cook Islands 97
Kiribati 92
Malaysia 78
DPR Korea 76
Sri Lanka 74
Thailand 72
Philippines 55
Singapore 42
New Zealand 39
Japan 35
Australia 31
0 50 100 150 200 250 300

Fig. 8.4 Age-standardized death rates (per 100 000 population) for stroke among males
in selected countries and areas in the Asia Pacific Region, 2005
Chapter 8
Sri Lanka 256
Vanuatu 201
Australia 178
Malaysia 175
Palau 159
Viet Nam 140
Mongolia 137
Lao PDR 136
Japan 136
Singapore 135
China 134
Bhutan 131
Samoa 127
India 126
Myanmar 126
Niue 121
Timor-Leste 119
Bangladesh 117
Tonga 116
Maldives 115
Nepal 111
Tuvalu 107
Solomon Islands 107
Indonesia 99
DPR Korea 87
Nauru 83
Cook Islands 83
Micronesia 77
Cambodia 66
Kiribati 57
Thailand 53
Philippines 47
New Zealand 42
Papua New Guinea 34
0 50 100 150 200 250 300

Table 8.1 Total DALYs lost due to cardiovascular disease in the Asia Pacific Region, 2005
DALYs (000s), all ages

Females Males
World Asia Pacific World Asia Pacific
Ischaemic heart disease 25 328 12 814 36 144 16 905

Cerebrovascular disease 24 374 12 982 26 411 15 703
Hypertensive heart disease1 3 840 1 839 4 023 2 167
2
Inflammatory heart disease 2 416 1 041 3 449 1 235
Rheumatic heart disease 3 193 2 259 2 566 1 866
Cardiovascular diseases 70 016 35 698 82 994 42 323
1
hypertensive heart disease is a late complication of hypertension in which the heart is affected
2
inflammatory heart disease is inflammation of the heart muscle and/or the tissue surrounding it.
Note: conditions are listed in descending order of total world burden.
Sources: WHO global infobase: data for saving lives. Geneva, World Health Organization. See: http://
Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS
medicine, 2006, 3(11), e442.
Rheumatic fever and rheumatic heart disease

Rheumatic fever and rheumatic heart disease remain a significant public health problem in developing
countries and in socioeconomically disadvantaged groups in developed countries, especially among
children. In 1994 it was estimated that 12 million people worldwide suffered from rheumatic fever
and rheumatic heart disease, and at least 3 million people had congestive heart failure due to rheumatic
heart disease that required repeated hospitalization.7,8
Both rheumatic fever and rheumatic heart disease are complications of Group A streptococcal
pharyngitis. The most common infections caused by Group A streptococci are streptococcus pharyngitis
and skin impetigo, with a peak in children aged 5–15.9
Reliable data are scarce on the incidence of rheumatic fever and rheumatic heart disease and in
many developing countries hospital morbidity data is all that is available. Based on this data, rheumatic
heart disease accounts for 12–65% of hospital admissions related to cardiovascular disease.10
The prevalence of rheumatic heart disease in the Asia Pacific Region has been estimated in surveys
of schoolchildren (Table 8.2). Although the data are old, they show that there is a wide variation
between and within countries, especially among ethnic groups.
It is generally accepted that socioeconomic and environmental factors greatly influence the incidence
and prevalence of rheumatic fever and rheumatic heart disease. Shortages of health-care provision and
expertise and low levels of awareness have major impacts on rheumatic heart disease, with crowding
exacerbating incidence. Conversely, prevention and early treatment of pharyngitis prevents rheumatic
fever and subsequent rheumatic heart disease from developing. For secondary prevention of rheumatic
heart disease, prophylactic use of long-acting penicillin is recommended.

Table 8.2 Reported prevalence of rheumatic heart disease in schoolchildren in the
Asia Pacific Region
Chapter 8
Country Year Rate per 1000 population
Australia (Northern Territory) 1989–1993 9.6

Cook Islands 1982 18.6
French Polynesia 1985 8.0
India 1984–1995 1.0–5.4
India (Northern) 1992–1993 1.9–4.8
Nepal (Kathmandu) 1997 1.2
New Zealand (Hamilton Maoris) 1983 6.5
New Zealand (Hamilton non-Maoris) 1983 0.9
Samoa 1999 77.8
Sri Lanka 1998 6.0
Source: Rheumatic fever and rheumatic heart disease. Report of a WHO Expert Consultation, Geneva, 2001.
Geneva, World Health Organization, 2001 (Technical report series no. 923).
Risk factors for cardiovascular disease

Elevated blood pressure
Hypertension, commonly known as high blood pressure, is a leading risk factor for CVD. Table 8.3
shows estimates of the mean systolic blood pressure (SBP) for people aged 30–44 in the Asia Pacific
Region in 2005. For SBP alone, the normal adult range is <120 mmHg and high-normal (pre-hypertensive)
120–139 mmHg. Hypertension is generally considered to begin at or above 140 mmHg.11,12
As with ischaemic heart disease and stroke, the general trend is for females to have lower mean
SBP values than males. The two exceptions are the Maldives and Papua New Guinea, with mean SBP
for females of 133.5 mmHg and 120.3 mmHg respectively. The mean SBP for Maldivian females is
the highest of all countries in the Region, for both males and females, and falls into the pre-hypertensive
range. The mean SBP for males of the Maldives, New Zealand, Tonga and Vanuatu also fall into the
pre-hypertensive range (Table 8.3).
Biological and behavioural risk factors

Heart disease and stroke share a group of common risk factors arising out of genetic factors, personal
behaviour and socioeconomic environments. These include:
• Raised blood lipids, raised blood pressure, impaired metabolism of glucose, and overweight
and obesity (especially central, or abdominal obesity) are a set of physiological risk factors
that lead to CVD and are frequently seen in clusters, with more than one present in the
same individuals at the same time.
• Tobacco use, physical inactivity, unhealthy diets and excessive alcohol consumption form an
antecedent cluster of behavioural risk factors, i.e. aspects of personal behaviour that are
associated with an increased risk of noncommunicable disease.
• The operation of these risk factors on individuals and populations is affected by certain non-
modifiable risk factors. Sex, ethnic group and age affect the severity of risk exposure and
vulnerability to CVD. For instance, increasing age brings a higher incidence of heart disease
and stroke and accounts for part of the rise in CVD in ageing populations.

Table 8.3 Mean systolic blood pressure and corresponding standard deviation (SD) among
adults aged 30–44 in selected countries of the Asia Pacific Region, 2005
Country Systolic blood pressure (mmHg)
Males Females
mean SD mean SD
Australia 114.1 11.7 122.6 15.2

Bangladesh 116.6 11.5 115.5 12.8
Bhutan 122.3 12.7 118.2 13.4
Brunei Darussalam 118.5 14.8 115.3 15.7
Cambodia 118.2 15.0 109.5 14.7
China 118.0 15.0 114.5 15.8
Cook Islands 126.7 15.2 124.2 16.2
Democratic People’s Republic of Korea 122.5 16.0 117.2 16.4
Timor-Leste 122.3 12.7 118.2 13.4
Fiji 115.2 12.7 109.8 13.1
India 123.8 13.0 120.9 14.0
Indonesia 121.3 15.4 120.0 16.8
Japan 125.4 14.1 116.2 13.7
Kiribati 126.0 15.0 115.7 14.4
Lao People’s Democratic Republic 118.2 15.0 109.5 14.7
Malaysia 118.8 14.9 111.7 14.9
Maldives 130.1 14.4 133.5 16.8
Marshall Islands 122.4 14.2 116.8 14.6
Micronesia, Federated States of 123.3 14.4 116.0 14.4
Mongolia 123.3 16.2 118.8 16.8
Myanmar 119.0 15.2 113.0 15.5
Nauru 127.9 15.5 117.7 14.8
Nepal 122.3 12.7 118.2 13.4
New Zealand 130.9 15.4 117.7 14.1
Niue 124.1 14.6 119.7 15.3
Palau 128.9 15.7 121.9 15.7
Papua New Guinea 117.1 13.1 120.3 15.4
Philippines 121.6 15.5 115.2 15.7
Republic of Korea 125.1 16.5 117.1 16.4
Samoa 124.3 14.6 112.8 13.7
Singapore 119.8 15.1 111.9 15.0
Solomon Islands 114.7 12.5 110.6 13.2
Sri Lanka 122.0 15.6 120.1 16.8
Thailand 116.1 14.3 112.4 15.1
Tonga 132.2 16.4 124.1 16.2
Tuvalu 122.4 14.2 116.8 14.6
Vanuatu 130.1 15.9 122.9 16.0
Viet Nam 117.8 14.9 114.0 15.7

Environmental risk
Personal risk factors are only a part of the CVD picture. As more people move to cities and economies
Chapter 8
grow, a number of social changes occur which directly increase CVD risk.
• Transport and work: The once ubiquitous bicycle is disappearing throughout Asia. Cityscapes
once dominated by this active, non-polluting form of transport have been overtaken by
successive waves of motorcycles and then cars, bringing noise, injuries and inactivity in the
rush for convenience and speed. In developing countries, most physical activity takes place
in transport and work domains, unlike developed countries where leisure-time physical activity
is much more important. The loss of cycling is not being replaced by other forms of activity
in the Region. With the move to cities, occupational patterns are changing too. Rural, active
occupations are replaced by more sedentary, urban jobs.
• Prices: The price of tobacco, alcohol, processed and fast food is often well within the
means of the growing income of the Region’s populations. A poor person in the Philippines
is able to purchase loose cigarettes,13 a beer,14 a mini-sized bottle of sugared soft drink15 and
a fast food combination meal for a total of not much more than US$ 1. 16 While conventional
wisdom suggests that these commodities are for the rich who can afford to buy them, the
marketing strategy of companies concerned will ensure availability for all but those living in
absolute poverty.
• Social norms: Norms are not changing as fast as economies develop. As many of the
Region’s countries emerge from times of major food insecurity, parents still consider an
overweight child healthy and slim one sickly. This compounds the problem of consumption
of unhealthy processed and convenience foods high in calories, fats and salt; and plays into
the hands of advertising aimed at children, which reinforces their changing dietary preferences.
• Policy myths: Despite overwhelming evidence to the contrary, national and international
policy-makers continue to cling to the belief that CVD is limited to the rich and that it is
possible to first deal with infectious diseases before solving problems of noncommunicable
diseases (NCD), or that the risk of CVD is determined by personal responsibility and not the
need for government intervention. There are many examples of what one might term
“myth-informed” policy-making.
These environmental factors, together with increasing longevity, are the main reason for the current
epidemics of NCD in general and CVD in particular. They must become the main points of intervention
if there is to be effective prevention. Campaigns that limit themselves to raising awareness and providing
information are doomed to fail and may simply be “blaming the victim” when the main attention
should focus on the causes and the social and environmental determinants of risk.
Health services as a determinant of cardiovascular diseases

A key environmental determinant of CVD morbidity and mortality is the health service itself. Apart
from the personal and environmental risks outlined above, the risk of developing a stroke, for example,
is strongly related to the control of blood pressure. Thus the management of raised blood pressure is
an intervention of major importance for the prevention of strokes and their recurrence.
Yet access to control of raised blood pressure is not given due priority in many developing countries
of the Asia Pacific Region, where most often there is no access to socialized medicine and private
medical services provide care for chronic diseases. Social health insurance schemes exist in some
countries (e.g. the Philippines, Sri Lanka, Thailand and Viet Nam), yet often there is no coverage for

regular drug treatment of raised blood pressure. Countries such as India are now beginning to put in
place risk factor surveillance as the first step towards a comprehensive NCD control programme
integrated with the public sector health delivery system.
Lowering cardiovascular risk in high-risk individuals

Several forms of therapy, including the lowering of blood lipids, blood pressure and blood sugar can
prevent CVD by decreasing the risk of coronary heart disease and stroke. There is a close association
between cardiovascular risk and levels of blood lipids, blood pressure and blood sugar. Therefore,
defining cut-off points for treatment based on single risk factor levels is arbitrary and can no longer be
justified. Treatment decisions need to be based on total cardiovascular risk.
Decisions about whether to initiate specific preventive action, and with what degree of intensity,
should be guided by estimation of the risk of vascular events. The recently released WHO/International
Society of Hypertension cardiovascular risk prediction charts for all WHO regions, allow treatment to
be targeted according to predictions of total cardiovascular risk.17 People with established coronary
heart disease or cerebrovascular disease are at very high risk of recurrent heart attacks and strokes and
need intensive interventions.18 For example, the effectiveness of statin drugs for lowering lipids in
those at high risk is well established. With regard to lowering lipids for primary prevention of CVD,
many studies confirm that the benefits depend on the level of cardiovascular risk: the higher the total
cardiovascular risk the greater the benefit. Overall, primary prevention trials have provided evidence
that lowering lipids with a statin is justifiable on risk-benefit grounds, and is cost-effective in subjects
who are at high risk of developing CVD, realizing a reduction in risk of over 20% over a period of
10 years.19 The CVD risk threshold for lowering lipids with statins should be decided at a national level,
because whether a risk threshold is cost-effective will, to a large extent, depend on the financial
resources available and the cost of statin drugs.
For those receiving treatment, ample anecdotal evidence shows that in developing countries of the
Region there is no easy access to effective counselling, and control of blood pressure is of poor quality.
The potential for prevention

There are numerous examples of a successful reduction of CVD burden or risk in countries such as
Finland, Mauritius and Poland. This section will consider a remarkable success in the Asia Pacific
Region—the fight against stroke in Japan. The overall change is seen in Figure 8.5.
From the year after the Tokyo Olympics (1964), an immediate and dramatic drop is seen for both
men and women in the age-adjusted mortality from stroke. This was a prominent feature of the health
transition in Japan over the last half century and contributed greatly to the increase in life expectancy.
One recent review20 estimated that the decline for all types of stroke averaged around 5% annually for
both men and women from 1965 to 1974, accelerated to a decline of around 8% annually from 1975
to 1989,21 and then slowed to an average 1% (men) and 3% (women) annual decline from 1990 to
1997.
The dramatic fall in stroke mortality in Japan over the last decades has been correlated with a
reduction in tobacco smoking and the control of blood pressure. The same study suggests that annual
declines in smoking and blood pressure in middle-aged and elderly men and women correlate with
declines in mortality. Such findings favour a combined primary, population approach (tobacco control,
salt reduction, alcohol control, physical activity and healthy diet) and secondary prevention (lowering
of cardiovascular risk by lowering blood pressure, blood lipids and blood sugar) as essential and
complementary techniques for preventing CVD.

Fig. 8.5 Age-adjusted mortality rates by sex for stroke and selected cardiovascular
diseases in Japan, 1950–2003
Chapter 8
400 400
age-adjusted mortality (per 100 000 pop.)
age-adjusted mortality (per 100 000 pop.)

Age -adjusted mortality [male] Age -adjusted mortality [female]
350 350 [source:vital statistics, disease classification
[source:vital statistics, disease
classification was changed in 1995] was changed in 1995]
300 300
250 250
200 200
150 150
100 100
50 50
0 0
2001
2001
50
50
'53
'56
'59
'62
'65
'68
'71
'74
'77
'80
'83
'86
'89
'92
'95
'98
'53
'56
'59
'62
'65
'68
'71
'74
'77
'80
'83
'86
'89
'92
'95
'98
cerebrovascular disease malignancy heart disease pneumonia suicide
Source: Public health of Japan 2007. Japan Public Health Association. Available from: http://www.jpha.or.jp/
jpha/english/index.html
Even though concerns have been expressed on the recent slowing of the decline of stroke mortality
in Japan, the rapidity and steepness of the fall lend great support to arguments that a rapid reversal of
the epidemic is possible and that the means to do so are within the resource constraints of developing
countries in the Region. The technology that brought about this decline in Japan is based on population
prevention and systematic primary care.
Reducing risk
The world health report 2002 – reducing risks, promoting healthy life22 estimated the burden of disease
by major risk factors for all regions of the world. It also estimated the cost-effectiveness of population
and high-risk interventions to prevent and control CVD. The report considered various scenarios for
CVD prevention and control that included population approaches (promoting small reductions in risk
across the whole population) and individual approaches (achieving major risk reduction in people at
high risk).
Examples of interventions deemed cost-effective (depending on the burden and specific country
situation) include:
• Tobacco control is the most cost-effective of interventions considered in this report, and
ranks high in the top five interventions for risk reduction worldwide. Taxation is the most
cost-effective of the tobacco control interventions, and from a pure NCD prevention
standpoint, the higher the rate of tax, the greater the effect. Advertising bans, control of
smoking in public places, and health education for tobacco control add to the range of cost-
effective interventions. Nicotine replacement therapy would be effective but adds considerably
to costs.
• Population-wide salt reductions, based on either voluntary agreements with industry to reduce
salt in processed food or on legislated changes with quality control and enforcement.
• Individual-based hypertension treatment and health education is cost-effective, especially if
it targets people with higher levels of blood pressure (systolic blood pressure above

160 mmHg)23. However, as there is a continuous relationship between cardiovascular risk
and blood pressure, blood lipids and blood sugar, the report does not recommend an approach
based on individual treatment of high blood pressure alone (single risk factor approach), but
that a comprehensive risk approach should be taken. In 2002, WHO produced a
comprehensive CVD-risk management package for low- and medium-resource settings.24
More recently, WHO released CVD prevention guidelines enabling a total risk approach,
which is feasible and cost-effective, even in low-resource settings.25
• Strategies to reduce cholesterol levels, whether through population-wide health education
or through individual approaches that provide statins to people with cholesterol above
6.2 mmol/l, were deemed very cost-effective in all regions.26,27
• Measures focused on the early detection and management of diabetes.
The WHO STEPwise approach to Chronic Disease Risk Factor

Surveillance
Cardiovascular disease prevention programmes can be integrated with others that share common risk
factors, such as diabetes, cancer and chronic respiratory disease. This can be organized in a WHO
STEPwise approach to Chronic Disease Risk Factor Surveillance (STEPS) fashion,28 which implies
that programmes would be evidence-based and devised in a manner that is responsive to resources
and other constraints in the country.
Using STEPS for intervention was first explored in the Pacific countries and areas; and the following
table from The world health report 2003 – shaping the future29 illustrates an example of such a
comprehensive, population-based, integrated STEPS package.
Table 8.4 was adapted from the proceedings of the Meeting of Ministers of Health for the Pacific
Island Countries in Nukualofa, Tonga, between 9 and 13 March 2003. As WHO moves to develop a
core package of interventions on NCD for publication in the near future, this table is reproduced for
historical purposes and to illustrate the contribution made by countries in the Asia Pacific Region to
global approaches in CVD and NCD control.
Planning, policies and programmes

Planning for CVD has been integrated with other aspects of NCD prevention and control covered in
this publication (tobacco page 313, diabetes page 302, rheumatic heart disease page 293 and nutrition
page 363). This section focuses on how to better understand the overall approach to the epidemic,
with selected examples of work being done.
As a result of country requests, high-level resolutions were adopted by WHO regional committees,30,31
for the development of global and regional frameworks for prevention and control of NCDs. Many
countries in the Region now have national NCD plans. Additionally, training in capacity building for
policy-makers and programme managers from health and other sectors has been undertaken, facilitated
by WHO.
The Tonga National NCD Plan 2003–2004 was the first STEPS plan developed, with the collaboration
of the Australian Agency for International Development and the Secretariat of the Pacific Community.
Viet Nam’s national NCD plan was the first of the Region’s developing countries to receive endorsement
at the highest level of government. Indonesia and Thailand have framed national integrated NCD
policies and strategies, and India launched the National Programme for Prevention and Control of
Diabetes, Cardiovascular Diseases and Stroke in late 2006.

Table 8.4 STEPS approaches for the prevention and control of noncommunicable
diseases
Chapter 8
Resource Population approaches Individual high-risk

Level National level Community level approach
Step 1: WHO Framework Convention Local infrastructure plans Context-specific

Core on Tobacco Control (FCTC) is include the provision and management guidelines for
ratified in the country. maintenance of accessible noncommunicable
and safe sites for physical diseases have been
Tobacco control legislation activity (such as parks and adopted and are used at all
consistent with the elements of pedestrian-only areas). health-care levels.
the FCTC is enacted and
enforced. Health-promoting A sustainable, accessible
community projects include and affordable supply of
A national nutrition and participatory actions to appropriate medication is
physical activity policy cope with the assured for priority
consistent with the Global environmental factors that noncommunicable
Strategy is developed and predispose to risk of diseases.
endorsed at cabinet level; noncommunicable diseases,
sustained multisectoral action is such as inactivity, unhealthy A system exists for the
evident to reduce fat intake, diet, tobacco and alcohol consistent, high-quality
reduce salt (with attention to use. application of clinical
iodized salt where guidelines and for the
appropriate); and promote fruit Active health promotion clinical audit of services
and vegetable consumption. programmes focusing on offered.
noncommunicable diseases
Health impact assessment of are implemented in settings A system for recall of
public policy is carried out such as villages, schools and patients with diabetes and
(i.e. transport, urban planning, workplaces. hypertension is in
taxation, and pollution). operation.
Step 2: Tobacco legislation provides Sustained, well-designed Systems are in place for
Expanded for incremental increases of tax programmes are in place to selective and targeted
on tobacco, and a proportion promote: prevention aimed at high-
of the revenue is earmarked for risk populations, based on
health promotion. • Tobacco-free lifestyles, absolute levels of risk.
e.g. smoke-free public
Food standards legislation is places and smoke-free
enacted and enforced, and sports;
includes nutrition labelling.
• Healthy diets, e.g. low-
Sustained, well-designed cost, low-fat goods, fresh
national programmes (counter- fruit and vegetables;
advertising) are in place to
promote non-smoking • Physical activity,
lifestyles. e.g. "movement" in
different domains
(occupational and
leisure).
Step 3: Country standards are Recreational and fitness Opportunistic screening,
Optimal established that regulate centres are available for case-finding and
marketing of unhealthy food to community use. management programmes
children. are implemented.
Capacity for health research is Support groups are fostered
built within countries by for tobacco cessation and
encouraging studies on overweight reduction.
noncommunicable diseases.
Appropriate diagnostic and
therapeutic interventions
are implemented.
Source: The world health report 2003: shaping the future. Geneva, World Health Organization, 2003.

Monitoring and surveillance
The STEPS approach covers the essential risk factors for CVD,32 and has been adopted as the standard
across the Asia Pacific Region. The last five years have seen STEPS surveys in 15 Pacific island countries
and/or STEPS-compatible surveys in China, Bangladesh, the Democratic People’s Republic of Korea,
India, Indonesia, Malaysia, Maldives, Mongolia, Myanmar, Nepal, the Philippines, Sri Lanka, Thailand
and Viet Nam.
This has created an invaluable and unique resource of comparable data sets on CVD and NCD risk
factors. They are currently in use in their countries of origin but efforts are being made to develop
policy mechanisms to permit a wider sharing of data. In South-East Asia, WHO has made progress with
the creation of an InfoBase consisting of data from STEPS and other surveys, becoming a unified
resource for researchers and policy-makers interested in comparable data on NCD.
Community-based initiatives for health promotion

In the Asia Pacific Region there has been an effort to foster community demonstration projects, with
most countries now able to report some action at the community level. These projects have had a
number of notable successes:
• In Cambodia, Mongolia and Viet Nam, NCD projects have attracted substantial external
funding and diabetes initiatives are spreading as a result.
• In the Philippines, projects among the Pateros and Guimaras communities were used as the
testing ground for a range of initiatives, which included the development of training materials
for primary care workers across the country, and contributed to the development of national
standards for primary care centres of wellness.
• Community-based interventions for prevention of NCD were implemented with WHO
support in Bangladesh, India, Indonesia and Sri Lanka. These projects furnished evidence on
the feasibility and appropriateness of applying community-based approaches for integrated
prevention and control of NCD in developing countries. A project in Depok, near Jakarta,
Indonesia, has gained considerable recognition and paved the way to initiate further subnational
interventions in Indonesia.
Clinical prevention guidelines

Through the work of ministries of health in many countries of the Region, and extensive technical
support from WHO, there are now evidence-based guidelines (usually in national languages) for the
control of elevated blood pressure and diabetes. This is only a first step. For both elevated blood
pressure and diabetes, there is a need to achieve good, lifelong control in order to reduce CVD
complications. Where evidence exists, for example in Cook Islands, India, Mongolia, Nepal and Viet
Nam, the level of clinical control of these conditions in primary care is poor. This is likely to be the
general case in developing countries of the Region and experiences point to a number of urgent health
systems developments that are still needed:
• Guidelines are only documents. Guidelines need intensive support for implementation,
including their incorporation into undergraduate and in-service training, and in quality assurance
and incentive mechanisms. These are still rare in the Region.
• Health systems are generally private. Insurance schemes, where present, only sporadically
cover CVD and NCD, and the burden usually falls on patients to buy lifelong treatment.

• There is insufficient investment in patient education and information. Chronic diseases
are best managed in a self-care setting and health-illiterate patients are less effective in self-
Chapter 8
care.
• Chronic diseases are handled in separate vertical programmes. While this is logical for
all chronic diseases, for instance HIV/AIDS, tuberculosis, cancer and CVD, in reality decisions
are made based on the availability of funds and the priorities of donors rather than the
burden of disease or community needs. Thus, individual vertical projects have evolved that
have resulted in fragmented care, rather than a wider, integrated health systems approach.
Network development
Networks are needed in the area of NCD prevention and control in order to foster communities of
practice among policy-makers with a responsibility for these diseases. The Region has developed
networks of managers involved in the area of NCD prevention and control.
The South-East Asia Network for NCD Prevention and Control (SEANET-NCD) has developed its
charter and plan of action at its regional meeting hosted by the Ministry of Health, Maldives, in
November 2005. The network plays an important role as a forum for promoting intercountry collaboration
in adopting an integrated approach to NCD control. It contributes to dissemination of information and
the exchange of expertise, and facilitates multisectoral, multidisciplinary and multilevel collaboration.
In the Western Pacific, a network has been operating since 2000 under the Western Pacific Declaration
on Diabetes (WPDD). Diabetes is a disease in its own right, but it is also a major risk factor for CVD,
and the work of WPDD is a direct contribution to CVD prevention and control. The work of WPDD is
further described on page 307. An informal network based on an electronic mailing list under the
name of Mobilization Of Allies in NCD Action (MOANA) has been operating since April 2006 and
serves as a source of news and updates for members.
Apart from the regional networks, similar networks are encouraged at the national level as a vehicle
for information dissemination and for joint advocacy. An example of excellence exists in the Philippines,
where a coalition of more than 40 governmental and nongovernmental agencies have come together
and, at the time of writing, are nearing the end of their third year of active collaboration.
Diabetes mellitus
Diabetes is a group of heterogeneous disorders characterized by hyperglycemia (high blood sugar
level) due to insulin deficiency, impaired effectiveness of insulin action, or both. Diabetes can lead to
serious complications, such as cardiovascular disease, stroke, blindness, renal failure, foot ulceration
and sensory neuropathy. Women with gestational diabetes (GDM) and children of GDM pregnancies
are at increased risk of developing diabetes and heart disease later in life.
Type 1 diabetes, Type 2 diabetes and GDM are of major public health importance. Type 1 diabetes
is most frequently first diagnosed in children and young adults and often has an autoimmune basis. In
most countries of the Asia Pacific Region, Type 1 diabetes accounts for less than 5% of diabetes cases,
except in Australia and New Zealand, where the figure is 10%–15%. Type 2 diabetes typically occurs
in adults, but is increasingly affecting all ages, including children. Type 2 diabetes accounts for
approximately 85%–95% of all diabetes cases in the Region.33 The highest prevalence is noted in
Pacific island countries and areas. This is due to rapid changes from traditional to more affluent lifestyles.
Gestational diabetes refers to glucose intolerance diagnosed for the first time during pregnancy.

There is currently little information available about modifiable risk factors for the development of
Type 1 diabetes. Type 2 diabetes is strongly associated with modifiable behavioural risk factors such as
overweight and obesity, abdominal obesity, physical inactivity, maternal diabetes, total fat intake,
some saturated and trans fats intakes, and intrauterine growth retardation. Obesity doubles the risk of
Type 2 diabetes.
Prevalence and mortality

In 2007 it was estimated that nearly 113 million people in the Region, or about 5.1% of the adult
population, have diabetes, and an additional 157 million adults (7.0%) have impaired glucose tolerance
(IGT).34 Figure 8.6 shows the 2007 prevalence estimates of diabetes and IGT by country. Estimates in
2000 showed that there were 2.9 million deaths worldwide directly due to diabetes, of which 51%, or
1.5 million deaths, were in the Asia Pacific Region. Worldwide, there were an additional 4.6 million
people with diabetes who died from other causes such as CVD. Therefore, annual mortality attributable
to diabetes in the Region could be over of two million.35,36
The prevalence figures shown are a substantial increase on previous years; and although detection,
diagnostic and surveillance techniques have improved, the incidence of diabetes in almost all countries
is increasing, following a general trend worldwide. Of the 44 countries listed, 30 have a significant
diabetes prevalence of 5% and higher. As could be expected, the general trend in IGT prevalence is
much higher than that of diabetes. Only seven countries have an IGT prevalence of less that 5%. If left
unmanaged, there is a strong possibility that IGT will develop into diabetes.37
What can be done: noncommunicable diseases programmes

Diabetes contributes greatly to other noncommunicable diseases and is part of the metabolic syndrome,
which is typically a set of risk factors that include: abdominal obesity, a decreased ability to process
glucose (diabetes, IGT, insulin resistance), dyslipidemia (unhealthy blood lipid levels), and hypertension.
These components of metabolic syndrome are intermediate risk factors for developing CVD. Many of
the common risk factors for diabetes are the same as those for CVD, as explained in Figure 8.7.
The control of underlying and intermediate risk factors will reduce the incidence of chronic diseases.
Therefore, comprehensive NCD programmes that include action on diabetes have been developed
with WHO support in many countries of the Region. This response to the NCD epidemic is outlined
in a framework based on four action areas: national planning, surveillance, healthy lifestyles and
environments, and clinical preventive services.
National planning
High-level policy interventions are needed to promote intersectoral collaborations to create an
environment that is conducive to the development of healthy lifestyles through informed choices.
WHO supports and encourages all countries in the Region in making comprehensive national NCD
policies and plans. As a result, integrated NCD policies and plans have been developed in most
countries, together with specific policies on tobacco, nutrition, physical activity, alcohol, hypertension,
diabetes and cancer.

Fig. 8.6 Prevalence estimates of diabetes and impaired glucose tolerance in the Asia
Pacific Region, 2007
Chapter 8
Source: Diabetes atlas. 3rd ed. Brussels, International Diabetes Federation, 2006.

Fig. 8.7 Critical pathways in the causation of chronic disease
BEHAVIOURAL
? Tobacco
? Diet
? Physical activity END-POINTS
? Alcohol
INTERMEDIATE ? Ischaemic heart dis.
ENVIRONMENTAL RISK FACTORS ? Stroke
? Sociocultural ? Hypertension ? Peripheral vasc. dis.
? Policy ? Blood lipids ? Cancer
? Economic ? Diabetes ? Chronic lung dis.
? Physical ? Obesity
NON-MODIFIABLE
? Age, sex, genes
Source: Preventing chronic diseases: a vital investment: WHO global report. Geneva, World Health Organization,
2005.
The creation of health promotion foundations for funding NCD prevention and control activities is
well underway. Several countries including Australia, Fiji, India, Malaysia, New Zealand, Thailand and
Tonga have passed legislation to enable the establishment of health promotion foundations. Elsewhere
in the world, health promotion foundations are involved in a wide range of activities funded from the
taxes imposed on items such as alcohol and tobacco. They also use strategies such as social marketing,
provision of health information and education, and the creation of environments and settings that are
supportive of health.
Surveillance
The WHO Stepwise approach to Risk Factor Surveillance (STEPS) framework for NCD intervention has
been accepted as the regional standard, and STEPS surveys have been undertaken, or are being
undertaken, in 30 countries in the Region. American Samoa, China, Cook Islands, Fiji, India, Indonesia,
Malaysia, the Marshall Islands, Mongolia, Nauru, Nepal, the Philippines, Samoa, Sri Lanka, Thailand,
Tokelau, Vanuatu and Viet Nam have undertaken STEPS surveys and have published reports. STEPS
surveillance technical meetings have been conducted in most of these countries to support them in
analysing the results of STEPS survey information.
The results have provided baselines on NCD and risk factor prevalence and identified priorities for
intervention programmes. In most of these countries, STEPS has been incorporated into the routine
health information system and will provide future data on trends and programme effectiveness.
Healthy lifestyles and environments

Many countries in the Region have developed demonstration activities in community-based prevention.
These include:

• Integrated community-based NCD prevention projects in Bangladesh, India and Indonesia.
• Childhood obesity reduction through health-promoting schools in China.
Chapter 8
• Diabetes control in Cook Islands.

• Development of a physical activity campaign in Mongolia.
• Diabetes prevention in two provinces in Viet Nam.
• Community projects on diet and physical activity in several Pacific island countries.
Guidelines for the monitoring of community-based interventions have been produced to facilitate
implementation of these projects.
Working in informal networks has been a tradition over the past years for NCD managers in the
Region. Exchange of knowledge and information is passed across the Region in this way. Maintenance
of networks is managed by regional organizations. Formalization of such networks can develop into
partnerships and coalitions that serve as effective mechanisms in NCD prevention and control. The
Philippine Coalition for the Prevention and Control of NCD and the developing Asia Pacific Physical
Activity Network are examples. In 2005 the South-East Asia Network for NCD Prevention and Control
was initiated with WHO support.
Clinical preventive services

In populations with established disease, improved control of blood glucose, blood lipids and blood
pressure, and use of appropriate treatment such as rennin-angiotensin system (RAS) blockers are
associated with marked reduction in morbidity and mortality due to cardiovascular and renal diseases.
Furthermore, the use of a multidisciplinary team with particular emphasis on patient empowerment,
treatment to target, and periodic assessments can lead to a 50%–70% reduction in mortality,
cardiovascular and renal events.38
Although the availability of diabetes education and care programmes will depend both on resources
available and current health-care infrastructure, given the highly preventable nature of complications
and the cost-effectiveness of many of these interventions it is suggested that all health-care systems,
across a wide range of resource levels, should be able to provide the medication, preventive care and
counselling to every patient, and educate health-care providers about the importance of these prevention
and intervention strategies.
WHO’s Innovative Care for Chronic Conditions (ICCC) Framework (Figure 8.8) outlines the
importance of integrating multiple components for patient and family (micro), health-care organizations
and community (meso), as well as policy and financing (macro) to make high-quality chronic care
possible. This comprehensive system aims to avoid fragmentation of care and emphasizes the need to
create a system which works across the disease continuum, spanning health promotion, disease
prevention, treatment and rehabilitation. Clinical management and care guidelines have been developed
in many countries.

Fig. 8.8 Innovative care for chronic conditions framework
Positive policy environment

l Strengthen partnerships l Integrate policies l Promote consistent financing
l Support legislative frameworks l Provide leadership and advocacy l Develop and allocate human
resources
Links
Health-care
Community P
r organization
e
p l Promote continuity and
l Raise awareness and coordination
a
reduce stigma r
e l Encourage quality through
l Encourage better tne ity
d leadership and incentives
par mun
outcomes through
He Tea
rs
leadership and support l Organize and equip
alt m
health-care teams
m
h-c
Mobilize and coordinate
Co
l
Use information systems
are
resources l
l Provide complementary l Support self-management

e d M and prevention
services rm ot
fo iva
In Patients and te
d
families
Better outcomes for chronic conditions
Source: The Innovative Care for Chronic Conditions Framework. Geneva, World Health Organization. Available
from: http://www.who.int/diabetesactiononline/about/ICCC/en/index.html
Specific activities on diabetes prevention and control in the Region

There are marked differences between the Asia Pacific Region and more developed regions such as
North America and Western Europe. Therefore, there is clearly a need to identify Regional and country
specific solutions for coping with the diabetes epidemic. In 2000, the Western Pacific Declaration on
Diabetes (WPDD) was developed in partnership with the International Diabetes Federation and the
Secretariat of the Pacific Community. The WPDD Action Plan 2000–2005, and more recently the
WPDD Action Plan 2005–2010, is a strategic approach to deal with the diabetes epidemic in the
Region.
A primary focus of the WPDD lies in its support of educational programmes and conferences to
increase regional awareness of diabetes as a priority health issue. These include the Diabetes Leadership
Workshop, 3rd Asia Pacific Epidemiology Course, and the 3rd World Congress on Prevention of Diabetes
and its Complications. Through these meetings and workshops, the WPDD has trained and
communicated with a large number of doctors, nurses, epidemiologists and related health-care workers

regarding the magnitude of diabetes as a public health problem, and the principles of conducting
research and developing education and care programmes in diabetes. Many of these participants have
Chapter 8
become champions and leaders in their own countries or areas by documenting facts and figures about
diabetes, initiating pilot clinical prevention programmes, and lobbying for government support to set
up national plans for the prevention of diabetes and its complications.
The WPDD Action Plan strategies have been instrumental in stimulating and supporting Cambodia,
China, Cook Islands, Fiji, India, Malaysia, the Marshall Islands, the Federated States of Micronesia,
Mongolia, the Philippines, Samoa, Tonga and Viet Nam to set up diabetes prevention and control
activities. In India, studies show that lifestyle modification or use of metformin is effective in preventing
diabetes in people with persistent IGT.
Cancer
A leading cause of death worldwide, cancer is a generic term for a group of more than 100 diseases
which can affect any part of the body, with lung, breast, colorectal, stomach and liver cancers being
the most common. The disease occurs through a pathological breakdown of the processes which
control the proliferation, differentiation and death of cells. Malignant cells which form a tumour most
frequently arise from the epithelial tissue and are known as carcinoma. More than 70% of all cancer
deaths occur in low- and middle-income countries; however, it must be kept in mind that these same
countries have a similarly large proportion of the world’s population.39 Cancer accounts for 13% of all
deaths in the Asia Pacific Region with demographic, socioeconomic and other characteristics producing
a wide variance in rates between individual countries.40 It is estimated that in 2000 there were
4.3 million cases and 2.9 million deaths from cancer in the Region, with lung cancer the most common.41
Cancer incidence and mortality is shown in Figure 8.9.
Fig. 8.9 Cancer incidence and mortality by sex and site of cancer in the Asia Pacific
Region, 2000
Males Females
2.387 millions cases 1.889 millions cases
1.741 millions deaths 1.186 millions deaths
Lung
Stomach
Liver
Colon/rectum
Oesophagus
Breast
Cervix uteri
Oral cavity
Leukaemia
Non-Hodgkin lymphoma
Pancreas
Brain, central nervous system
Bladder
Ovary etc. Incidence
Prostate Mortality
Other pharynx
500 400 300 200 100 0 100 200 300 400 500
(thousands)
Source: Ferlay J, et al. GLOBOCAN 2002: Cancer incidence, mortality and prevalence worldwide. Lyon, IARC
Press, 2004 (IARC CancerBase No: 5. version 2.0).

Major types of cancer
The age-standardized incidence of lung cancer in males per 100 000 population ranges from 53 in
Korea and 42 in China to less than 10 in India and Sri Lanka.42 Tobacco smoking causes a wide range
of cardiovascular and respiratory diseases, including cancer of the lungs and other organs. If strong anti-
tobacco measures within the WHO Framework Convention on Tobacco Control are not properly
implemented, it is anticipated that lung cancer rates will continue to rise. Prevention is critical as
therapy for lung cancer is irrelevant and early detection is not useful.
Stomach cancer is another common cancer in the Asia Pacific Region, largely caused by Helicobacter
pylori infection. The path of transmission of Helicobacter infection is still unclear. High consumption of
salt and salted, smoked, pickled and preserved food is another cause, but the introduction of refrigerators
in Japan reduced the use of traditional preservatives and thereby rates of stomach cancer. The prevalence
of stomach cancer in China is likewise dropping due to better methods of food preservation. Preventive
measures include improving the quality of food and lowering salt intake. Stomach cancer rates range
from less than 70 per 100 000 in China, Japan and South-East Asia to less than 6 per 100 000 in India
and Sri Lanka.43 In these countries, the disease carries a very high mortality due to lack of access to
early diagnosis.
Liver cancer is the third major cancer in the Asia Pacific Region, with approximately
470 000 people affected annually. The age-standardized incidence rate per 100 000 people for liver
cancer ranges from 100 to less than 15. More than two thirds of liver cancer cases occur in men. Since
it is invariably lethal, the number of deaths due to this cancer is as high as the incidence. While liver
cancer is predominantly caused by hepatitis B infection, in countries such as Japan hepatitis C infection
is a significant cause. The incidence of liver cancer is likely to drop over the next 20 years through
higher immunization coverage for hepatitis B, and when the vaccine eventually becomes available it
should drop for hepatitis C. Most of the middle-income countries and some least-developed ones in
the Region have included immunization against hepatitis B as part of WHO’s Expanded Programme on
Immunization (EPI). It must be kept in mind that because immunization is carried out in childhood, for
routine immunization against hepatitis B to show an impact on the incidence of cancer of the liver it
would be necessary to wait for the immunized cohort to reach the age when cancer of the liver
manifests itself. Even in countries where there is low endemicity of hepatitis, chronic alcoholism
predisposes heavy drinkers to liver cancer. Aflatoxins in food also enhance the risk of liver cancer.
Breast cancer is the most common cancer among women in the Asia Pacific Region. In a few
countries in the Region it is second only to cancer of the uterine cervix. Age-standardized rates range
from 92 per 100 000 in New Zealand to less than 20 per 100 000 in China and India.44 Breast cancer
is intimately related to a high-calorie diet, lack of exercise and reproductive factors. Early detection
through proper screening and improvements in therapy have reduced mortality. Unfortunately, early
detection and therapy are inaccessible to large segments of the population in the Region.
Cancer of the uterine cervix is another major disease affecting women and is caused by sexually
transmitted Human papillomavirus (HPV) infection. It is also associated with socioeconomic conditions.
While the age-standardized incidence in India is above 30 per 100 000 population, it is less than
10 per 100 000 in China and Australia.45 Rates are dropping in India due to improved socioeconomic
conditions.46 Further improvement requires the introduction of an active screening programme, such
as the cytological Pap test or visual inspection with acetic acid (VIA). Survival can be improved
considerably by early detection linked with radiotherapy treatment, but developing countries lack the
financial resources to carry out such a cytological screening programme. Alternative methods more
suitable for low-resource countries, such as VIA followed by cryotherapy, are under investigation.

Cancer of the oral cavity caused by chewing tobacco ranks among the three most common types
of cancer in south-central Asia.47 Tobacco is chewed alone or with lime, betel leaf, betel nut and other
Chapter 8
compounds as a combination called paan, a local combination used with or without tobacco now
being replaced largely by pre-packed pan masala granules. Both paan and paan masala, especially
when they contain tobacco, can lead to corrosion of the oral mucosa, leukoplakia or submucus fibrosis,
and eventually, cancer. Legislation on tobacco in many countries has been silent on use and sale of
these products. Countries with the greatest burden of oral cancer in men are Papua New Guinea,
Solomon Islands and Sri Lanka.
The data as presented above serve to highlight the fact that the distribution of types and sites of
cancer vary greatly from country to country. This difference has also been demonstrated in different
parts of the same country. India has generated good data on the distribution of types of cancer by its
network of cancer hospital and community-based registries and shows a very marked difference in the
type of cancer found in different states. Such data have value in planning education and awareness
programmes specific and relevant to the local situation.
Risk factors for cancer

Tobacco use remains the major preventable risk factor for cancer. In other parts of the world, active
and passive tobacco smoking is the main cancer risk, but in the Asia Pacific Region the widespread use
of chewing forms of tobacco is a leading cause of oral cancer. In parts of China and South-East Asia,
and especially in north-west India, Indonesia, Malaysia and Singapore, there are high rates of
nasopharyngeal cancer, with the main causal factors being smoking and alcohol.48,49
The Region bears a heavy burden of cancer due to various acute and chronic infections. This
includes endemic liver cancer due to hepatitis B and C. There is a very high incidence of stomach
cancer in China, Japan, Mongolia and the Republic of Korea largely due to Helicobacter pylori infection.50
In South Asia, cancer of the uterine cervix due to HPV infection is prevalent.
Two other major risk factors alcohol and improper diet—are of importance in the Region. Heavy
alcohol consumption is a major risk factor for cancers of the oral cavity, larynx, pharynx, oesophagus,
liver and breast. It is estimated that alcohol consumption results in 5% of attributable cancer deaths in
low- and middle-income countries.51 Diet-related cancers, such as breast, colon and cancer of the
prostate, have shown only a mild increase during the last decade.
Strategies for cancer control

Approximately 40% of cancers could be avoided through primary prevention by avoiding or reducing
risk, and one third could be cured if diagnosed early.52 Those with incurable cancers should receive
appropriate palliative care, but there are several constraints to achieving these goals. Effective cancer
control requires a comprehensive national cancer control policy and programme with adequate resource
allocation, development of diagnostic and therapeutic capacity, and good resource utilization in palliative
care. High levels of female illiteracy, gender discrimination and other forms of socioeconomic
inequalities, as well as poor enforcement of tobacco, alcohol and other food and drug legislation
hinders the efforts of cancer control programmes in many countries in the Asia Pacific Region.
The WHO Strategy for Prevention and Control of Cancer aims to reduce the cancer burden and
risk factors and improve the quality of life of patients and their families. In 2005, the 58th World
Health Assembly adopted Resolution WHA58.22 on cancer prevention and control, which calls for
the reinforcement of national cancer prevention and control programmes and integrating them with

health systems, strengthening information systems (like cancer registries), and ensuring the availability
of opiate analgesics. Table 8.5 compiles the information on major strategies available for prevention
and control of eight common cancers occurring in the Asia Pacific Region.
Cancer registries, either hospital- or community-based, such as those set up in India, serve an
important preventive role as they provide information about the area-specific prevalence of different
types and locations of cancer. This knowledge is important not only for advocacy but can also ideally
be used to develop evidence-based intervention programmes.
Table 8.5 Assessment of strategies for eight common cancers

Site of cancer Prevention Early detection Curative therapy Palliative care
Effectiveness Cost Effectiveness Cost Effectiveness Cost Effectiveness Cost
Mouth/pharynx ++ $ - $$ + $$ ++ $
Oesophagus + $ - - ++ $
Stomach ++ $ + $$ - ++ $
Colon/rectum ++ $ + $$ + $$ ++ $
Liver ++ $ - - ++ $
Lung ++ $ - - ++ $
Breast + $ ++ $ ++ $ ++ $
Cervix + $ ++ $ ++ $ ++ $
++ Effective; + partly effective; - largely ineffective
$ Less expensive; $$ more expensive
Source: National cancer control programmes: policies and managerial guidelines. 2nd ed. Geneva, World
Health Organization, 2002.
Primary prevention
Childhood immunization against hepatitis B is the most cost-effective strategy to prevent adult mortality
from liver cancer. Several vaccines have been developed for cervical cancer caused by HPV. The safety
profiles of these vaccines are very good and the immunity produced has been found to be satisfactory
in prevention of the disease. Broad introduction of HPV vaccine, especially in low-resource settings, is
hindered by its high cost and other challenges in implementing vaccination programmes.
Tobacco use, a common cause of cancer in the Region, accounts for 18% of disability-adjusted life
years lost.53 Two forms of tobacco use, chewing and smoking, are highly prevalent in the Region and
each cause cancer in different parts of the body. While cigarette smoking is prevalent in China and
many South-East Asian countries, chewing tobacco is predominant in Central and South Asia. Oral
tobacco use is also associated with cancer of the oral cavity, whereas smoking tobacco causes cancer
of the lung, larynx, pancreas, stomach, bladder and cervix. The long-term strategy for control of
tobacco-related cancer involves education, advocacy, and legislative and fiscal measures.
Colorectal cancer is another cancer in which primary prevention is feasible through improvement
in diet and related lifestyle modifications. The risk for colorectal cancer can be reduced by limiting
meat consumption and increasing intake of vegetables and fruits. The major difficulty in shifting to a
healthy diet is the rising cost and inadequate availability of vegetables and fruits. This shortage could
be mitigated by better horticultural and marketing practices. Lack of physical activity is another risk

factor for colorectal cancer. With socioeconomic advancement, there is a tendency to refrigerate food
in middle- and upper-class households. This may reduce stomach cancer rates attributed to salted,
Chapter 8
pickled and preserved food. A joint programme for control of chronic diseases aimed at lowering salt
consumption can reduce hypertension as well as stomach cancer.
Early detection of common cancers

For many cancers such as those of the lung, oesophagus, stomach and liver, early detection is of no
significant value. Three types in which early detection has proven value are oral cavity, breast and
cervical cancers. Only in the case of oral cancer has a feasible and cost-effective screening strategy
been developed. The adoption of this strategy could prevent at least 37 000 deaths worldwide every
year.54
Mammography is the gold standard for early detection of breast cancer. It can reduce mortality by
up to one third among women age 50–69.55 But mammography is a high-cost, technology-intensive
screening procedure beyond the reach of most developing countries. Monthly self-examination of the
breast and periodic breast examination by trained technical personnel have demonstrated a marginal
improvement in survival rates. Even though such screening may not yield detection rates as high as
mammography, it can certainly lead to earlier detection and thereby provide a better chance of a cure.
Cytology-based screening and treatment programmes have reduced cervical cancer incidence and
mortality by as much as 80% in North America and the Nordic countries of Europe.56 Broad
implementation of this approach in the Asia Pacific Region is hindered by financial constraints and
inadequate health infrastructure and outreach. Alternate strategies like visual inspection with acetic
acid are being proposed. To implement such a programme on a national scale, the investment in basic
health infrastructure, including human resources and facilities, is considerable, as a substantial proportion
of women may require further coloscopy, biopsy, Pap smear, cryosurgery or close follow-up for which
the services of pathologists, gynaecologists and health workers are essential.
Early detection of colorectal cancer, which is predominant in East Asia, is a formidable challenge.
Even though primary prevention would be the long-term goal, early detection and therapy should be
considered as an appropriate approach, since many countries have adequate resources and good
health system infrastructure. Colonoscopy is the preferred method of early detection of colorectal
cancer. As colonoscopy is impractical for screening of asymptomatic individuals, it should be restricted
to a subpopulation of people over age 50, identified through a risk-factor questionnaire. Screening with
faecal occult blood test, which is more acceptable, requires further evaluation in settings where it is
proposed for use.
Early diagnosis in symptomatic populations depends upon raising awareness of early warning signs
and symptoms of various types of cancer, and motivating people to seek early examination, investigation
and treatment. This approach is particularly successful when used to detect mouth, cervix and breast
cancer, which contribute to 50% of the cancer burden.
Therapy for cancer

Among the major cancers occurring in the Asia Pacific Region, early treatment is of value in cancers of
the head and neck, colon and rectum, breast, and cervix. There are several other tumours where early
treatment results are excellent, such as childhood cancer and germ cell tumours. The predominant
forms of cancer treatment are surgery, radiation and chemotherapy. The type of cancers which are

curable, with their approximate load in India and modality of treatment, are given in Table 8.6.
Palliative care should be extended to people with advanced stages of cancer that cannot be treated by
presently available modalities.
The major difficulty in the management of cancer in the Region is the inaccessibility of treatment
and care due to geographical and financial constraints. Countries such as Bangladesh, Bhutan and
Timor-Leste have very little access to either radiotherapy or other modern cancer treatment services.
Specialists are few and tend to be located in metropolitan areas. In the absence of appropriate financial
mechanisms and protection, out-of-pocket payments for the treatment of cancer can devastate families
and individuals. The cost of installation and maintenance of equipment stands in the way of equitable
radiotherapy service. The recent manufacture in India of new cobalt units under US$ 200 000, is
expected to help fill this gap. The Chinese linear accelerator programme already provides access to
radiotherapy for many people. The introduction of Indian and Chinese generic drugs has improved the
affordability of cancer chemotherapy in the Region.
Table 8.6 Curable cancers for which treatment is justifiable, India

Cancer Load % Primary modality
Childhood cancer 5 CT/S/RT
Breast 20 S/RT/CT/HT
Cervix 18 RT/S
Oral 11 RT/S
Gestational trophoblastic disease 1 CT
Germ cell tumours 3 CT/S
Colon 7 S/CT
Osteosarcoma 2 CT/S
Soft tissue sarcomas 2 S/RT
Central nervous system 2 S/RT
Total 71
CT- chemotherapy, S – surgery, RT – radiotherapy, HT – hormone therapy
Source: Nair MK, Varghese C, Swaminathan R. Cancer: current scenario, intervention strategies and projections
for 2015. In: Burden of disease in India. New Delhi, National Commission on Macroeconomics and
Health, 2005 (Background papers): 219.
8.2 Chronic noncommunicable diseases and the

WHO Framework Convention on Tobacco
Control
The tobacco epidemic
Chronic noncommunicable diseases accounted for almost 60% of global deaths and 47% of the global
burden of disease in 2005.57,58 The global tobacco epidemic is the second major cause of all deaths
from NCD, and the fourth most common risk factor for disease worldwide; and is responsible for
almost five million deaths in 2006, mostly in low- and middle- income countries. If current smoking

patterns continue, almost 10 million deaths will result annually by 2025.59 Half of the 650 million who
smoke today will eventually be killed by their habit. In the Asia Pacific Region alone, about
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6000 people a day die prematurely from tobacco-use related diseases, a death toll of 2.3 million
annually. In addition, millions of nonsmoking adults and children in the Region are exposed to tobacco
smoke pollution (also known as second-hand smoke and environmental tobacco smoke), which causes
death, disease and disability.60
The economic costs of tobacco use are equally devastating. In addition to the high public health
costs of treatment, tobacco-caused diseases kill people at the height of their productivity, depriving
families of breadwinners and nations of a healthy workforce. Globalization of the tobacco epidemic
has been instigated by the tobacco industry which targets youth and disadvantaged groups and takes
advantage of weak control measures and a lack of public awareness of the dangers of tobacco use,
especially in developing countries.
Tobacco use patterns

Compared with other regions the Asia Pacific Region has the greatest number of smokers, estimated
at 661.6 million; the highest rates of male smoking prevalence and the fastest increase in tobacco use
by women and young people. In most countries, tobacco use is more prevalent among the poor and
disadvantaged segments of the population.
While cigarette smoking predominates, a variety of tobacco products are consumed in the Region.
Tobacco is chewed, sucked, sniffed and gargled using zarda, khaini, betel leaf, gutkha, gul, mawa, betel
quid and mishri. There are specific indigenous smoking products such as bidis and hukkas/hookahs
(hubble bubble) in India and Bangladesh, kreteks in Indonesia, and cheroots and bamboo waterpipes
in Cambodia, the Lao People’s Democratic Republic, Myanmar and Viet Nam, and betel nut chewed
with tobacco in many Micronesian countries as well as Papua New Guinea and Palau. In some countries,
various tobacco products are combined or have supplanted other forms of tobacco use. For example,
in India there has been an overall reduction in the use of bidis and cigarettes but an increase in
smokeless tobacco use in rural areas. There is also use of shisha waterpipes (also known as hookahs,
bhangs or nargiles) in nightclubs and restaurants in Brunei Darussalam, India, Malaysia and Thailand.61,62
Smoking prevalence has decreased in the past decade in developed countries such as Australia,
Japan, New Zealand and the Republic of Korea. In less than five years cigarette smoking among
Korean men dropped from 61.8% to 52.8%, one of the most significant declines worldwide.63 Tobacco
prevalence is still very high among men in the Region (up to 45% in some areas), with smoking rates
as high as 60%–70%. Smoking is increasing in developing countries, and among young women and
youth in some countries. Tobacco use among women is as low as 3%–4% in the Region, but there are
several notable exceptions. For example, 50.8% of women in Nauru smoke tobacco daily.64 In many
other Pacific island countries the majority of women smoke or use other tobacco products. Tobacco
use, especially smoking among young women, appears to be increasing in many countries including
China, Malaysia, the Republic of Korea and many Pacific island countries. 65
In the Region boys are significantly more likely than girls to smoke cigarettes.66 In 7 of 29 sites
within the Region (i.e., WHO Member States and their populations) included in the Global Youth
Tobacco Survey, 15% or more students aged 13–15 years currently use tobacco products other than
cigarettes.67 Similarly, 25% or more of the youth surveyed currently use cigarettes in 7 of 29 sites.68
However, these figures may be misleading as some countries in the Region have not yet surveyed
youth tobacco use and the Global Youth Tobacco Survey is not representative of all youths aged 13–15
from participating countries. In Thailand, 19.3% of youth currently use tobacco products and 13.8%

smoke cigarettes. In Cook Islands, current cigarette use prevalence among girls is 49.6%; and in Papua
New Guinea, current cigarette use prevalence among boys is 52.1%, the highest in the Region.69 Only
1.2% of youth aged 13–15 in Hanoi, Viet Nam, currently smoke cigarettes.70
In general, smoking by youth in the Asia Pacific Region is increasing and the average age at which
people begin smoking is dropping from the early twenties to the teens. However, youth smoking rates
are beginning to fall in countries where effective tobacco control measures have been implemented.
In the Philippines following enforcement of municipal smoking bans, male youth current cigarette
smoking prevalence declined by approximately one third, from 32.6% in 2000 to 21.8% in 2003.
Among adolescent girls the decline was similar, from 12.9% in 2000 to 8.8% in 2003.71 However,
according to the 2007 Global Youth Tobacco Survey data, current cigarette smoking prevalence among
male and female youth increased to 23.4% and 11.8%, respectively.72 Reasons for this increase are
currently being explored. The Republic of Korea instituted consecutive tax increases over a five-year
period and introduced health education campaigns, which may have contributed to cutting male youth
smoking in half from 35.3% in 1997 to 15.9% in 2004.73
Exposure to tobacco smoke pollution

Exposure to tobacco smoke pollution increases non-smokers’ frequency of chronic respiratory conditions
and raises their risk of acute coronary artery diseases by 25%–35%. Evidence links tobacco smoke
pollution to other adverse health effects in adults, including exacerbation of asthma and reduced lung
function. Small children whose parents smoke at home have a greater risk of suffering lower tract
respiratory infections, inner ear infections, more frequent and severe asthma episodes, and the risk of
Sudden Infant Death Syndrome (SIDS). 74
People’s exposure to tobacco smoke pollution in the Region, especially children, is staggeringly
high. Most are involuntarily exposed inside their homes or in public places. In Jakarta, over 81.6% of
children aged 13–15 are exposed to tobacco smoke pollution in public and almost 66.8% in their
homes.75 A seminal 1981 Japanese study found that non-smoking women married to men who smoke
had significantly increased risk of lung cancer compared to non-smoking women married to non-
smoking men.76 In China a study found that exposure to tobacco smoke pollution kills as many women
as does smoking; and estimated that in 2002, 48 400 women died from lung cancer and ischaemic
heart disease attributed to exposure to tobacco smoke pollution compared with 47 300 lung cancer
and heart disease deaths from smoking.77
Burden of tobacco use

World Bank estimates in 1993 showed that the global net social cost of smoking—factoring in the net
social benefit of smoking—was US$ 200 billion each year.78 This huge economic burden is now
shifting from developed countries to developing countries.79 About 75% of today’s tobacco users live
in developing countries, and most live in the Asia Pacific Region.80 By 2030, developing countries will
account for 70% of all tobacco deaths.81
Globally, tobacco use tends to be higher among groups with less education and less income and
this holds true for most of the Asia Pacific Region. Poorer households spend a greater percentage of
their income on tobacco than wealthier ones, and often children suffer most. Research from a broad
range of countries shows that as much as 25% of household income is spent on tobacco and is given
priority over other basic necessities of life, including food, clothing, health care and education.82 In
Viet Nam, for example, tobacco spending is often 1.5 times higher than that for education, five times

higher than health-care expenditures, and is one third of food budgets.83 In China’s Minhang district,
smokers spent 17% of household income on cigarettes.84 In Bangladesh, for example, money spent on
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tobacco is about 5% of total household expenditure. Poor people spend proportionately more compared
to rich people and suffer and die more as a consequence of tobacco-related diseases.85 Even homeless
children in India spent a significant portion of their income purchasing tobacco, often prioritizing it
over food.
Tobacco-related illnesses account for 16% of deaths in Bangladesh among people aged 30 and
above. Of all hospital admissions for this age-group one quarter are due to tobacco-related illnesses,
which imposed a net cost of US$ 442 million on the economy in 2004.86 Table 8.7 shows the relative
risk and population attributable risk of smoking two different forms of tobacco on selected NCD in
Bangladesh.
Table 8.7 Relative risk (RR) and population-attributable risk (PAR) of selected NCD for
tobacco usage in Bangladesh
Smoking tobacco Non-smoking tobacco
Diseases
RR PAR (%) RR PAR (%)
Ischaemic heart disease 1.5 21.4 2.0 25.3

Stroke 1.2 10.7 2.2 29.1
Buerger’s disease 28.1 93.4 1.4 10.4
Oral cancer 4.8 66.3 2.5 30.5
Lung cancer 5.3 69.8 1.4 11.3
Laryngeal cancer 10.0 82.7 1.4 9.9
Chronic obstructive pulmonary disease 3.0 52.5 1.8 18.5
Source: Impact of tobacco-related illnesses in Bangladesh. New Delhi, WHO Regional Office for South-East
Asia, 2007.
In India about one million people die every year due to tobacco-related diseases. In the Philippines,
researchers have conservatively estimated total annual costs of illness for just four smoking-related
diseases—cerebrovascular diseases, coronary artery disease, chronic obstructive pulmonary diseases
and lung cancer—at US$ 2.86 billion, while real costs may be as high as US$ 6.05 billion each year.87
Tobacco use-related impairment of fetal nutrition, resulting in low birth weight, may be another
vascular risk factor relevant to the Asia Pacific Region. It has been implicated in the causation of
metabolic syndrome and diabetes, as well as in the mediation of vascular risk through other risk factors
such as high blood pressure. The association may have profound effects on the incidence of diabetes
and cardiovascular diseases in parts of the Region where tobacco use-related fetal malnutrition is
common.
Progress of the WHO Framework Convention on Tobacco Control in the

Asia Pacific Region
The challenge to public health is to avert this epidemic and its severe socioeconomic effects by
prompt implementation of effective interventions through a proper, legally binding international
framework. In response to the global tobacco epidemic, WHO Member States adopted the first global

tobacco control treaty—the WHO Framework Convention on Tobacco Control (WHO FCTC)—in
May 2003. The objective of the treaty is to “protect present and future generations from the devastating
health, social, environmental and economic consequences of tobacco consumption and exposure to
tobacco smoke” by reducing tobacco use prevalence and exposure to tobacco smoke pollution through
measures at the national, regional and international levels. The treaty entered into force on
27 February 2005, and as of March 2007 over 140 countries had ratified it, making it one of the most
rapidly embraced treaties of all time.
In contrast to previous drug control treaties, the Framework Convention asserts the importance of
demand reduction strategies as well as supply issues. The Framework Convention will help reduce
tobacco use and exposure to tobacco smoke pollution in a number of ways. These, among other
things, include the following:
• protect young people from exposure to tobacco use and from using tobacco;
• prevent people from taking up smoking, and help those who want to quit;
• ban smoking in public places and transportation;
• take steps to promote economies that are not dependent on tobacco products;
• strengthen women’s roles in tobacco control;
• aid countries by teaching people about the dangers of tobacco; and
• protect communities most vulnerable to tobacco, especially indigenous populations.
Asia Pacific countries played an active role in all stages of the Framework Convention process from
the beginning of initial negotiations to the adoption and ratification of the treaty. As of January 2007,
36 of 38 WHO Member States in the Region have become Contracting Parties to the Convention,
indicating strong support and commitment to the treaty.
Several countries in the Asia Pacific Region now have comprehensive national tobacco control
legislation conforming to the provisions of the Framework Convention. Australia, Bangladesh, Brunei
Darussalam, India, Singapore, Malaysia, Myanmar, New Zealand, the Philippines, the Republic of
Korea, Sri Lanka, Thailand and Viet Nam have undertaken significant efforts to control tobacco use
though comprehensive legislation while others are in the process of developing legislation. All countries
are putting in place necessary administrative, infrastructural and legislative measures, in line with the
provisions of the Convention. Some countries in the Region have integrated several elements, linking
tobacco control activities to NCD prevention.
WHO Framework Convention and its linkage to noncommunicable diseases

Globally, NCD are increasingly recognized as a major cause of morbidity and mortality. According to
the 2005 WHO global report preventing chronic diseases: a vital investment,88 global action to prevent
chronic disease could save 36 million people who would otherwise die by 2015. Underlying determinants
for NCD in the Region are rapid ill-planned urbanization, expanding industrialization, rising incomes,
globalization and ageing population. The rapid pace of change is resulting in a high prevalence of
common behavioural risk factors, namely, tobacco use, alcohol abuse, unhealthy diets and physical
inactivity.
Tobacco use combined with exposure to second-hand smoke is the major component for NCD risk
factors,89 and its control would greatly benefit the Region. Numerous studies reveal that tobacco
cultivation and use is harmful to a country’s economy and 90, 91 the health costs associated with tobacco

use far outweigh any revenues. The WHO Framework Convention is the most effective tool to reduce
tobacco consumption and can significantly reduce morbidity and mortality from NCD. Reducing tobacco
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use significantly reduces health-care expenses, money that could be spent to promote healthy lifestyles
which provide greater workforce productivity and beneficial national economic gains.
Box 8.1: Thailand: pioneering tobacco control
Thailand has one of the strongest and most comprehensive tobacco control laws and measures
in the Asia Pacific Region, with provisions of the Framework Convention and tobacco control
best practices comprehensively reflected in its tobacco control measures. The salient features
of best practices are:
• Total bans on advertising, promotion and sponsorship, such as direct advertising, point-of-
sale advertising, product placement in all media and trademark diversification.
• Ban on all forms of promotion, e.g. free giveaways, exchanges, rebates, discounts, free
premiums and others.
• Limit youth access through prohibition of sales to minors less than age 18, and a ban on
cigarette vending machines.
• Disclosure of the constituents and emissions of products to the Ministry of Public Health;
Thailand being one of only two countries in the world to have such a section of the law.
• Labelling of cigarette packages with six rotary pictorial health warnings, making Thailand
the fourth country in the world to have such graphic warnings.
• Prohibition on import, production and sale of smokeless tobacco products.
• Prohibition on import, production and sale of hookah.
• Comprehensive smoking ban in public places and workplaces, including all public transport,
cinemas, stores and air-conditioned restaurants.
• Strong presence and advocacy by civil society organizations, including foundations, institutes
and nongovernmental organizations for tobacco control.
• Taxes from tobacco used for anti-tobacco and other health promotion activities.
Conclusions and recommendations

The Framework Convention is inextricably linked to future efforts to prevent NCD and effective
implementation of the Convention and strict enforcement of tobacco control measures will significantly
reduce their incidence.
Formidable challenges lie ahead in reducing illness and death from tobacco use in the Asia Pacific
Region due to pervasive poverty and resource constraints in many countries. As the tobacco industry
actively obstructs public health initiatives and efforts to reduce tobacco use, it is crucial that public
education and advocacy for a healthy lifestyle, including campaigns against tobacco use, are intensified.

8.3 Injuries and violence
Injuries caused an estimated 5.2 million deaths worldwide, 9% of total, and resulted in
182 million DALYs lost in 2002, the latest year for which complete data are available.92 If current trends
continue, road traffic and intentional injuries (self-inflicted injuries or suicide, and interpersonal violence)
will rank among the 20 leading causes of death by 2030 (Table 8.8).
Table 8.8 World rankings of injury-related mortality in 2002 and 2030

Ranking in terms of the number of deaths
Type of injury
Year 2002 Year 2030
Road traffic injuries 10 8
Self-inflicted injuries 14 13
Interpersonal violence 21 19
Source: Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS
medicine, 2006, 3(11), e442.
In the Asia Pacific Region it is estimated that injuries caused about 2.7 million deaths in 2002, or
over 7000 deaths daily, which constituted 52% of worldwide injury deaths. The injury burden amounted
to some 92.5 million DALYs lost in the Region in 2002, 51% of the global total (Table 8.9). Low- and
middle-income countries have higher injury-related mortality rates than high-income countries. The
5-44 age group accounted for 55% of injury-related mortality. In 2002, the major causes of injury
deaths in the Region were due to road traffic (an estimated 600 000 deaths), self-inflicted injury or
suicide (577 000), falls (237 000), drowning (230 000), burns (204 000), interpersonal violence
(179 000), and poisoning (170 000).93 Unintentional injuries and those due to violence are significant
public health problems in the Region.
Table 8.9 Injury-related mortality and burden of disease in the Asia Pacific Region in 2002
Mortality Burden of disease
No. of deaths % of the DALYs lost % of the
(thousands) world total (thousands) world total
All types of injuries 2 696 52 92 521 51
Road traffic injuries 600 50 18 919 49
Self-inflicted, suicide 577 66 13 959 67
Falls 237 61 10 201 63
Drowning 230 60 6 555 60
Burns 204 65 7 184 63
Interpersonal violence 179 32 5 877 27
Poisoning 170 49 3 433 46
Source: Revised global burden of disease (GBD) 2002 estimates. Geneva, World Health Organization. Available
from: http://www.who.int/healthinfo/bodgbd2002revised/en/index.html

Mortality and DALYs lost due to road traffic injuries, self-inflicted injuries, drowning and burns in
the Region were almost equal to or more than 50% of the respective world totals.94 The Asia Pacific
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Region has a very high burden of injuries compared to other regions.
In response to these injury-related problems, some governments (e.g. China, Mongolia, Myanmar,
Thailand, Sri Lanka and Viet Nam) have developed national policies, plans and programmes for injury
prevention and others have started public awareness programmes. However, there are still many
challenges faced by developing countries of the Region in solving injury problems. These include
insufficient awareness and understanding of the magnitude and cause of injuries; lack of national
policies and plans for injury prevention; and limited national capacity to collect and analyse injury data
and design and implement effective interventions.
Road traffic injuries

Road traffic is a major cause of injuries and deaths throughout the Asia Pacific Region. Pedestrians,
bicyclists and motorcyclists are the most vulnerable road users and suffer the majority of fatalities and
injuries. In most countries where rapid motorization is taking place, road traffic injuries are
correspondingly rising in number and severity. Besides the ever-increasing number of cars and motorcycles
other factors contributing to rising road traffic injuries include speeding; driving under the influence of
alcohol; the lack of helmets, seat-belts, child restraints and other protective measures; mixed motorized
and non-motorized transport; and poor road infrastructure and signage.
Many developing countries in the Region have recently passed, or are in the process of passing,
legislation that mandates the use of helmets and seat-belts, sets speed limits and safety standards for
motor vehicles, prohibits drinking and driving, and requires the use of daytime headlamps by
motorcyclists. Legislation for child restraints may soon follow. However, law enforcement is not always
successful.
In collaboration with the Asian Development Bank, countries of the Association of South East Asian
Nations (ASEAN) developed national action plans for road safety in 2004 and have begun to implement
them. Each country takes a multisectoral approach to road safety, involving transport, police, education,
health and other departments. In Thailand, for example, a nationwide multisectoral project is piloted
at the provincial level to promote motorcycle safety. Another multisectoral project promotes the use
of motorcycle helmets for children aged 2–14 and focuses on three major components of behaviour
modification: a predisposing factor (risk communication and education for appropriate use of motorcycle
helmets); an enabling factor (production of child motorcycle helmets and availability in the pilot area);
and a reinforcing factor (control and monitoring by families, schools, society and the police of the
appropriate use of motorcycles and helmets for children).
The health sector is intensely involved in improving injury surveillance and emergency medical
care systems and advocating for prevention and behavioural changes for motorists and non-motorist
road users. The presence of an emergency response system that reaches the site of a road accident
swiftly, provides on-the-spot immediate initial care and arranges for the safe transport of patients to
properly equipped trauma units can save lives and minimize disability. Such networks are being established
in some of the larger metropolitan areas in the Region.

In other developing countries, the multisectoral approach to road safety has become popular. In
China, the ministries of public security, health, and communication have increased collaboration in
reducing road traffic injuries and deaths. An alliance involving these government departments and the
private sector has also been formed to tackle the increasing risk of road traffic to human health and
lives.
The United Nations Road Safety Week, coordinated by WHO, has strongly supported multisectoral
coordination to prevent road traffic injuries.
Suicide
Suicide is a major cause of injury deaths in the Asia Pacific Region and is often related to a state of
impaired mental health or depression. Different social and economic factors affect the mental state of
people and rates of suicide. The availability of poisons (e.g. pesticides and harmful substances) is
linked to the occurrence of suicide. (Further discussion on this issue is provided in this publication’s
section on mental health.)
Research and investigation in the Region have shown that depression is not as strong a causal factor
in suicide as impulse, and this link should be systematically explored to provide guidance for an
appropriate response, including focusing attention on reducing access to the means of suicide.
Regarding interventions, programmes which screen for those at high risk can also create stigma that
lowers compliance. Researchers should seek population-wide positive approaches for prevention.
Other innovative approaches are also being tried. For example, with the collaboration of
nongovernmental organizations India has established telephone help lines for the depressed in many
large urban areas.
Drowning
Drowning is a leading cause of death in children under the age of 15 in many countries including
Bangladesh, China and Thailand.95 It is the most common cause of unintentional deaths in Bangladesh
and Maldives. Most drowning deaths take place in ponds, rivers and oceans, or during floods and
typhoons. Very few are related to swimming pools.
Since victims of drowning have a slim chance of survival after immersion, prevention strategies are
important. Limiting access by fencing off deep bodies of water has proven effective, but is not always
possible. Drowning deaths during water recreation can be prevented by adult supervision of children,
swimming instruction, and the training of lifeguards.
For surface water transport, legislation and enforcement of provisions for personal flotation and
other lifesaving devices, and avoidance of overloading can prevent mass casualties. In the case of
floods and storms, preventive measures include early warning and evacuation to safer places and
prompt rescue activities.
Burns
Burns are a major injury problem in Asia, particularly in South Asia. The majority of burns occur at
home. The risk factors associated with burns include cooking on open fires, explosion of pressure
stoves, instability of small stoves, use of open fires to keep warm during winter, and the use of
inflammable materials in housing and furnishings. Housing and clothing fires are the most severe
events but not as frequent as scalds from hot liquids. Use of fireworks during festivals and celebrations

is common in Asia and leads to a significant number of burn injuries. Multiple deaths also occur each
year from fires and explosions in factories and homes that manufacture fireworks. The lack of adequate
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treatment of burns in developing countries is also a factor that increases the severity of the injury.
Effective prevention interventions include promotion of more stable stands for lamps and stoves;
installation of smoke detectors, fire alarms and extinguishers in houses and buildings; the provision of
clear access to emergency exits, banning or strictly controlling the use and sale of fireworks, increased
use of flame-retardant fabrics and materials, and the provision of first aid and treatment of burns.
These practices are not common in developing countries and would require appropriate rules and
regulations on product safety standards, close monitoring, and education. Improvements to infrastructure
for cooking and heating are also likely to reduce the incidence of burns.
Violence
Interpersonal violence—such as child abuse and neglect, violence against intimate partners, elder
abuse and homicide—is a major public health problem in the Asia Pacific Region, but its magnitude
and causes are not fully known. However, some countries, such as Malaysia, Mongolia, Nepal, Sri
Lanka and Thailand have completed a national report on violence and health and other countries are
beginning to address the issue.
Effective interventions may include the control of lethal weapons; alcohol and drugs; documentation
of cases of violence; advocacy for violence prevention; improved care for victims; promotion of gender
and social equity; empowerment of weaker sections of society; and the promotion of life skills in
children and parents, such as communication skills and discipline techniques that do not employ
physical violence.
8.4 Mental and neurological illnesses and

substance abuse
Mental and behavioural disorders are defined in the International Statistical Classification of Diseases
and Related Health Problems, Tenth Revision (ICD-10) as a set of clinically recognizable behavioural
and psychological problems, accompanied by severe and long-lasting distress, disability, or impairment
in one or more important areas of functioning, and a significantly increased risk of suffering, pain,
disability, loss of freedom, or death. Examples of these disorders include schizophrenia, anxiety and
depression. The latter is a condition closely associated with suicide. Mental and behavioural disorders
also include mental retardation—characterized by intellectual difficulties that have their onset in
childhood—as well as psychosocial problems, such as those related to the use of psychoactive substances
and traumatic stress situations. Neurological disorders which cause substantial morbidity and mortality
include epilepsy, stroke, Parkinsonism and headache, and are classified elsewhere in ICD-10.
Magnitude of the burden from mental and neurological

disorders
Mental disorders do not spare any age, gender, class, social status or cultural group. They are found
among rich and poor and in urban and rural areas in all countries. The notion that mental disorders are
problems of the rich, industrialized nations is simply wrong, as is the belief that mental disorders do
not exist in rural communities because they remain relatively unaffected by the fast pace of modern
life.

An estimated 450 million people suffer from mental and neurological disorders worldwide.96 Millions
more suffer from so-called sub-threshold disorders, and experience often disabling psychological
problems, even when their symptoms do not satisfy the criteria of a psychiatric condition as defined in
current classification systems. Surveys conducted in developed as well as developing countries show
that at least 2% of the population suffer from the most severe forms of mental disorder, such as
schizophrenia, dementia, severe mental retardation and the consequences of brain injuries. Less
severe but still disabling forms, such as depressive disorders, anxiety and obsessive-compulsive disorders,
affect a further 3%–4% of the population. Mental retardation, often coexisting with other mental
disorders, affects a further 2%–3% of the population in several countries. Table 8.10 is a summary of
the disease burden of selected major mental disorders in the Asian Pacific Region.
Magnitude of the burden from alcohol abuse

Problems related to alcohol abuse and dependence vary in their frequency and severity among countries,
but are reported as a major concern for public health in many countries. Data from the WHO Global
status report on alcohol 2004 show that there has been a steady increase in per capita consumption in
many countries in the Asia Pacific Region since the mid-1980s. Some developed countries, such as
Australia, Japan and New Zealand, have relatively high per capita consumption (6–9 litres of pure
alcohol per year for those 15 years of age and above).97 In some developing countries such as China,
India, Viet Nam and most countries and areas in the Pacific, per capita consumption is relatively low
but increasing rapidly. A recent study conducted on a sample of 3258 individuals drawn from rural,
town, slum and urban areas in India found that nearly 33% of the adult population regularly consumed
alcohol.98 In China, for example, per capita annual alcohol consumption for those 15 years of age or
above was 0.75 litres in 1970 but rose to 4.45 litres in 2001.99
Alcohol is rapidly becoming one of the most significant risks to public health, roughly of the same
magnitude as tobacco. Further, changing patterns of drinking—such as binge drinking and more frequent
and heavy drinking among young people—tend to lead to more harm. In addition to the impact on
public health, there are substantial social and economic costs associated with the harmful use of
alcohol. Alcohol-related problems not only affect the individual drinker but have a significant effect on
others, including family members, victims of violence and accidents associated with alcohol use, and
the community as a whole. The harmful use of alcohol results in considerable expense through lost
productivity and costs to the health and welfare, transportation, and criminal justice systems.
One estimate puts the yearly economic cost of alcohol abuse in Australia to be around 1% of the gross
domestic product.100 It is estimated that the Government of India spends nearly US$ 6.2 billion every
year to manage the consequences of alcohol use, which is more than its total excise earning
(US$ 5.5 billion).101
Mental health resources

Data from the WHO Mental health atlas 2005 reveals that a mental health policy and substance abuse
policy are present in 50%–58% of countries.102 Only about half of all countries have a specified budget
for mental health, and even where this exists, it is very often less than 1% of the total health budget.
In almost one fifth of all countries, out-of-pocket payments are the primary means for obtaining care,
a method which is a significant barrier to continued and adequate care.
The widespread stigma and discrimination against people who are mentally ill makes the provision
of mental health care particularly difficult. Stigmatization leads to the rejection of patients and their
families by communities and triggers negative discrimination with respect to access to treatment,

housing, employment and health insurance. The stigma attached to mental illness also makes psychiatry
an unattractive choice of career for health professionals, which contributes to the continuing shortage
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of mental health professionals and the inadequacy of mental health services.
Table 8.10 Burden of neuropsychiatric diseases worldwide and in the Asia Pacific Region,
2002
World Asia Pacific
DALYs Percentage Percentage DALYs Percentage Percentage

Neuropsychiatric disease lost of total of neuro- lost of total of neuro-
(thousands) disease psychiatric (thousands) disease psychiatric
burden burden burden burden
1 Unipolar depressive 67 295 4.52 34.82 36 501 5.28 38.48
disorders
2 Bipolar disorder 13 952 0.94 7.22 7 633 1.10 8.05
3 Schizophrenia 16 149 1.08 8.36 9 309 1.35 9.81
4 Epilepsy 7 328 0.49 3.79 3 420 0.49 3.61
5 Alcohol use disorders 20 331 1.36 10.52 8 272 1.20 8.72
6 Alzheimer and other 10 397 0.70 5.38 4 722 0.68 4.98
dementias
7 Parkinson disease 1 570 0.11 0.81 631 0.09 0.67
8 Multiple sclerosis 1 477 0.10 0.76 716 0.10 0.75
9 Drug use disorders 7 388 0.50 3.82 1 366 0.20 1.44
10 Post-traumatic stress 3 335 0.22 1.73 1 841 0.27 1.94
disorder
11 Obsessive-compulsive 4 923 0.33 2.55 1 837 0.27 1.94
disorder
12 Panic disorder 6 758 0.45 3.50 3 662 0.53 3.86
13 Insomnia (primary) 3 477 0.23 1.80 1 703 0.25 1.80
14 Migraine 7 666 0.51 3.97 3 999 0.58 4.22
15 Mental retardation, 9 956 0.67 5.15 4 837 0.70 5.10
lead-caused
16 Other neuropsychiatric 11 277 0.76 5.83 4 399 0.64 4.64
disorders
Total 193 278 94 848
Source: Revised global burden of disease (GBD) 2002 estimates. Geneva, World Health Organization. Available
from: http://www.who.int/healthinfo/bodgbd2002revised/en/index.html.
The importance of mental health was recognized by WHO in its Constitution, which states: “Health
is not merely the absence of disease or infirmity but rather a state of complete physical, mental and
social well-being”. The World health report on mental health: new understanding, new hope, published
in 2001,103 was a landmark in the formulation and promotion of policies and the training of health
professionals involved with mental health.
The World health report on mental health recommended, among other actions, that treatment of
mental disorders should be provided within the primary health-care setting, psychotropic drugs should
be made available, care should be given in the community, the general public should be educated on
mental health issues, and that communities, families and consumers be involved in mental health

care. The report also emphasized the importance of establishing national policies, programmes and
legislation; stressed the need for the development of human resources for mental health care and
reiterated; the importance of creating links with other sectors and of developing monitoring mechanisms
for community mental health and the importance of conducting relevant research.
Development of community-based mental health systems to

meet the essential needs of the community
Many countries in the Asia Pacific Region have noted that large segments of their population, particularly
in rural and remote areas, do not receive appropriate care for people with common neuropsychiatric
conditions. Patients are taken to faith-healers instead of doctors. These observations have led to the
development of community-based strategies to reach the unreached segments of the population.
In order to illustrate best practices in mental health care in the community through use of information
exchange, current evidence and practical experience, WHO has developed the Asia-Pacific Community
Mental Health Project. The project was instrumental in the formation of a network of key representatives
from ministries of health and organizations working in community mental health in the Region.
Suicide prevention
There is a shared view that suicide is a major public health concern in the Asian Pacific Region. The
WHO Suicide Trends in At-Risk Countries and Territories (START) project was launched in March 2006
to promote to the creation of national databases, and to understand the various types of suicidal
behaviour, certify suicide deaths and develop effective interventions.
Promotion of mental health

Concepts of mental health promotion, evidence for mental health promotion and strategies to be
implemented the same are being developed throughout the Region. Two settings for mental health
promotion activities are being given special attention. The first setting is adolescents, both in school
and out of school. The suggested tools for this setting include life skills education, prevention of harm
from alcohol and strategies for coping with stress. In the community setting, the recommended tools
are building community resilience, prevention of harm from alcohol and using traditional methods
such as meditation for coping with stress.
The experiences in the Asia Pacific Region over the past years have indicated that changes in
mental health programmes require strong and persistent political commitment, and a reorientation of
health systems to include mental health services as an essential component at all levels. Most importantly,
substantial improvement of mental health can only be possible when there is a change of attitude
towards mental health at both the community and government levels.
Control of alcohol-related harm

Growing awareness of the public health impact of the harmful use of alcohol led to action in 2005 at the
Fifty-eighth World Health Assembly. Core areas for national action and regional collaboration were identified
through consultations with key stakeholders. These include reducing the risk of harmful use of alcohol;
minimizing the impact of its harmful use; regulating its accessibility and availability; and establishing
mechanisms to facilitate and sustain implementation of the public health-oriented alcohol policy. There
is general consensus over the fact that isolated measures such as media campaigns are unlikely to have
effect. For effective control of alcohol-related harm a comprehensive and consistent set of measures is

required, involving a wide range of sectors and adapted to the national context. Some countries in the
Region, such as Australia, New Zealand, the Republic of Korea and Thailand to mention just a few, have
Chapter 8
already taken up the challenge to define and implement policies that provide better protection against
the harm associated with alcohol.
8.5 Thalassaemia
Thalassaemia is a hereditary blood haemoglobin disorder that results in varying degrees of anaemia.
Although the disease was identified in the early 1950s, it is only in recent decades that its etiology,
diagnosis, clinical syndromes and outcomes have been clarified. Thalassaemia is classified both by
clinical manifestation and genetic background. The most common types of thalassaemia syndrome are
alpha (α) and beta (β) thalassaemia, classified by which part of the haemoglobin molecule is lacking
from red blood cells. Both forms of thalassaemia are prevalent in the Asia Pacific Region. The most
severe form of α-thalassaemia, Hb Bart’s Hydrops Fetalis, mainly affects those of South-East Asian,
Chinese and Filipino ancestry and results in death during the fetal or newborn period. Many individuals
with α-thalassaemia have milder forms of the disease with varying degrees of anaemia. β-thalassaemia
ranges from a very severe form of anaemia with growth retardation—like the β-thalassaemia major,
also called Cooley’s anaemia—to a very mild form with no health effects.
Thalassaemia is a major cause of mortality and morbidity in the Asia Pacific Region. The growing
demand on resources for the care of thalassaemia patients makes the disease an important public
health issue. Available information on the prevalence of thalassaemia in selected countries and areas
of the Region is shown in Table 8.11.
Table 8.11 Prevalence of thalassaemia and abnormal haemoglobins in selected countries

in the Asia Pacific Region
Country % carriers
α β Hb E Hb CS
Bangladesh ... 3 4 ...
Cambodia (+) (+) (+) ...
China, Guangxi 15 5 (+) ...
China, Hong Kong 2.2 3–6 ... ...
India 5–97 3–4 (+) (+)
Indonesia 6–16 3–10 1–25 ...
Lao People’s Democratic (+) (+) (+)
Republic
Malaysia (+) 4.5 (+) (+)
Maldives 28 18 0.7 0.4
Myanmar 10 0.5–1.5 2–28 ...
Singapore 2.9 0.9 0.6 ...
Sri Lanka (+) 2.2 0.5 ...
Thailand 10–30 3–9 10–53 ...
Viet Nam 2.5 1.5 (+) ...
(+) = abnormal gene present, exact frequency not known.
... Data not available.
Source: Fucharoen S, Winichagoon P. Preventional and control of thalassemia in Asia. Asian biomedicine, 2007,
1 (1): 1-6.

Prevention
Prevention is the key strategy of thalassaemia control. This includes carrier screening, genetic counselling
and prenatal diagnosis for at-risk couples. Blood examination and family studies can identify individuals
with thalassaemia and asymptomatic carriers. Health education programmes, testing for the genetic
trait, counselling and prenatal diagnosis help families make informed decisions and bear healthy children.
Prenatal testing of fetal cells collected through cordocentesis, chorionic villus sampling or amniocentesis
can detect or rule out thalassaemia in the fetus. Introduction of prenatal diagnosis with selective
abortion is considered an important factor in the success of thalassaemia prevention programmes.
However, medical termination of pregnancy is an ethical and legal issue in many countries.
Treatment
Thalassaemia carriers have no symptoms and thus require no treatment. Presently, many children born
with major forms of thalassaemia are dying undiagnosed or untreated before age 10 due to anaemia
and infection. Children with thalassaemia major require frequent blood transfusions to prevent
complications and improve their quality of life, but this carries the risk of acquiring blood-borne diseases
such as hepatitis, HIV, malaria and syphilis. Moreover, frequent blood transfusions lead to an accumulation
of iron in the body which can damage the heart, liver and other vital organs. For many years
desferrioxamine, administered daily by pump, was the only therapy for patients with iron overload.
The administration of an iron chelator (chelation therapy) helps eliminate excess iron and prevents or
delays problems related to iron overload and toxicity. Children with thalassaemia major who are
treated with frequent blood transfusions and properly managed chelation therapy can live more than
30 years. Patients older than age 5 may benefit from a splenectomy. For a minority of patients who
have a suitable donor and can afford the costly treatment, thalassaemia can also be treated by bone
marrow or stem cell transplantation. There are numerous obstacles to providing appropriate treatment
for thalassaemia. A lack of blood supplies means transfusions are unavailable to many patients, and
often transfusion safety measures are inadequate. Chelation therapy can average US$ 250–US$ 300
per month and the pump for subcutaneous infusion costs approximately US$ 500.
National prevention and control programmes

Thalassaemia poses a significant burden on the health services and economic resources of many
countries in the Asia Pacific Region. With advances in knowledge and technology it is now possible to
effectively prevent and control the disease. Highly successful programmes have been implemented in
Mediterranean countries such as Cyprus, Greece and Italy.
The WHO Regional Committee for South-East Asia in 1995 adopted resolution RC48.R3 on
prevention, control and treatment of thalassaemia. The resolution urged Member States to increase
community awareness of thalassaemia and requested WHO to facilitate an exchange of information.
The Scientific Debate on Prevention and Control of Thalassaemia at the 28th South-East Asia Advisory
Committee on Health Research held in 2003 recommended the strengthening of collaborative research
on epidemiology, diagnostic and treatment methods, as well as health system research on development,
implementation, monitoring and evaluation of models for the prevention and control of thalassaemia.
Increasingly, prevention programmes are being introduced in many parts of Asia such as China,
India, Indonesia, Malaysia, Maldives and Singapore. National thalassaemia programmes in Thailand
and some other countries are producing positive, measurable results. The prevention and control of
thalassaemia serves as a good model for the introduction of comprehensive programmes for the
control of other common genetic disorders.

The overall goal of a thalassaemia programme is to ensure the provision of basic facilities, skills and
knowledge for prevention and management. Such programmes should be integrated into existing
Chapter 8
health-care systems. The main components of a national programme include:
• carrier screening in communities known to have patients with thalassaemia;

• integrating counselling by health services and the training of primary health-care staff;
• ensuring community involvement and public education;
• strengthening therapeutic services;
• providing adequate safe blood supplies and affordable chelation agents;
• prenatal diagnosis and selective termination of pregnancy; and
• monitoring and evaluation through maintaining registries of the number of new births, patients
and prenatal diagnoses made.
Programmes should be developed that take into account the social and cultural needs of the
community. Collaboration among countries in the areas of information sharing, human resources
development, technical cooperation, research and technology transfer should be encouraged. The
Asian Thalassaemia Network established in 2003 provides a promising forum for international
collaboration.
Box 8.2: Prevention and control of thalassaemia in Thailand
The National Prevention and Control Programme for Thalassaemia was launched in Thailand in
1994 as a collaboration between the Thalassaemia Foundation of Thailand, university research
groups and the Ministry of Public Health. The basis for prevention and control has been the
adoption of phenotypic screening followed by counselling and prenatal diagnosis. In response
to the need for a screening programme, a test was developed that incorporated primary screening
for osmotic fragility followed by a simple dye test. The combination has been effective in
detecting a wide range of thalassaemia phenotypes, including α-thalassaemia-1, β-thalassaemia,
haemoglobin E and iron deficiency. A more specific test for α-thalassaemia-1 has also been
available for some time. In terms of prenatal diagnosis, cordocentesis, amniocentesis and chorionic
villi sampling are used to obtain fetal tissue for haemoglobin and genetic analysis.
Following a successful pilot programme, a model for the prevention and control of severe
thalassaemia was expanded in 1998 to all of Thailand. In 2000, the thalassaemia programme
was integrated into the existing health-care system with the Department of Health, universities,
regional health centres, and general, district and community hospitals; coordinating a range of
services including policy development, education, research, technical support, counselling and
screening. In 2001 thalassaemia screening was formally covered by government health-care
policy. Available statistics indicated that 518 thalassaemia cases had been prevented since the
implementation of the programme. There are now 25 centres offering prenatal diagnosis in
Thailand.

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29 The world health report 2003: shaping the future. Geneva, World Health Organization, 2003: 89.
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34 Ibid.
35 Roglic G, et al. Burden of mortality attributable to diabetes: realistic estimates for the year 2000. Diabetes
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36 Wild S, et al. Global prevalance of diabetes: estimates for the year 2000 and projections for 2030.
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42 Ibid.
43 Ibid.
44 Ibid.
45 Ibid.
46 National Cancer Registry Programme. Consolidated report of the population based cancer registries 1990-
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69 Ibid.
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86 Ibid.
87 Baquilod MM, Crisostomo M, Yurekli A. Tobacco and poverty study in the Philippines. Paper presented at
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Chapter 8
88 Preventing chronic diseases: a vital investment: WHO global report. Geneva, World Health Organization,
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89 Op cit. Ref 1.
90 Op cit. Ref 81.
91 Op cit. Ref 59.
92 Revised global burden of disease (GBD) 2002 estimates. Geneva, World Health Organization. Available
from: http://www.who.int/healthinfo/bodgbd2002revised/en/index.html
93 Ibid.
94 Ibid.
95 Child injury in Asia—time for action. Bangkok, the Alliance for Safe Children (TASC) and the United Nations
Children’s Fund (UNICEF) East Asia and Pacific Regional Office, 2004.
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97 Global status report on alcohol 2004. Geneva, World Health Organization, 2004.
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for South-East Asia, 2006 (Alcohol control series no. 1).
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WHO Regional Committee for the Western Pacific, Auckland, New Zealand, 2006. Available from: http:/
/www.wpro.who.int/media_centre/press_releases/pr_20060920.htm
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8

public health treaty, the WHO Framework Convention on Tobacco Control.

8.1 Lifestyle diseases

288 Health in Asia and the Pacific

0 50 100 150 200 250 300 350

Priority noncommunicable diseases and conditions 289

0 50 100 150 200 250 300 350

290 Health in Asia and the Pacific

Marshall Islands 161

Lao PDR 146

Solomon Islands 123

Viet Nam 108

Papua New Guinea 100

0 50 100 150 200 250 300

Age-standardized death rate per 100 000 population

Priority noncommunicable diseases and conditions 291

Sri Lanka 256

Brunei Darussalam 176

Republic of Korea 166

Viet Nam 140

Lao PDR 136

Marshall Islands 117

Solomon Islands 107

Papua New Guinea 34

0 50 100 150 200 250 300

Age-standardized death rate per 100 000 population

292 Health in Asia and the Pacific

DALYs (000s), all ages

Ischaemic heart disease 25 328 12 814 36 144 16 905

Rheumatic fever and rheumatic heart disease

Priority noncommunicable diseases and conditions 293

Country Year Rate per 1000 population

Australia (Northern Territory) 1989–1993 9.6

Risk factors for cardiovascular disease

Biological and behavioural risk factors

294 Health in Asia and the Pacific

Australia 114.1 11.7 122.6 15.2

Priority noncommunicable diseases and conditions 295

Health services as a determinant of cardiovascular diseases

296 Health in Asia and the Pacific

Lowering cardiovascular risk in high-risk individuals

The potential for prevention

Priority noncommunicable diseases and conditions 297

age-adjusted mortality (per 100 000 pop.)

298 Health in Asia and the Pacific

The WHO STEPwise approach to Chronic Disease Risk Factor

Planning, policies and programmes

Priority noncommunicable diseases and conditions 299

Resource Population approaches Individual high-risk

Step 1: WHO Framework Convention Local infrastructure plans Context-specific

300 Health in Asia and the Pacific

Community-based initiatives for health promotion

Clinical prevention guidelines

Priority noncommunicable diseases and conditions 301

302 Health in Asia and the Pacific

Prevalence and mortality

What can be done: noncommunicable diseases programmes

Priority noncommunicable diseases and conditions 303

304 Health in Asia and the Pacific

Healthy lifestyles and environments

Priority noncommunicable diseases and conditions 305

• Diabetes control in Cook Islands.

Clinical preventive services